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INDICATIONS   FOR  OPERATION 
In   Disease  of  the  Internal  Organs. 


INDICATIONS 
FOR    OPERATION 

IN  DISEASE  OF  THE  INTERNAL  ORGANS. 


BY 

Prof.     HERMANN     SCHI.ESINGER,     M.D., 

Ext7aordi>iary  Professor  of  Medicine  in  the    University  of  Vienna. 

Aiithorized     English      Translatioji 

BY 

KEITH     W.     MONSARRAT,     M.B.,     F.R.C.S.Ed., 

Surgeon   to   the  Northern   Hospital,   Lizwi-pool. 


K.    R.   TREAT   &   Co.,   241-243,   West   23rd  Street. 
1906. 


Vj 


) 


TRANSLATOR'S     PREFACE. 

Professor  Schlesinger's  reputation  as  a  clinician  and 
writer  is  in  itself  sufficient  explanation  for  this  translation. 
The  subject  of  his  treatise  is  admittedly  one  of  the  first 
importance.  Now  that  the  activities  of  surgery  are  so 
far-reaching,  the  question  of  the  indications  for  operation 
is  one  which  is  constantly  presenting  itself  to  the  prac- 
titioner, and  one  which  is  often  very  difficult  of  decision. 
The  object  of  this  volume  is  to  aid  in  the  settlement  of 
such  problems,  and  I  have  undertaken  its  translation 
because  it  appears  to  me  eminently  to  succeed  in  its 
purpose. 

K.    W.  MONSARRAT. 

Liverpool,  July,  1906. 


AUTHOR'S    PREFACE. 

I  HAVE  been  induced  to  write  this  book  by  the  fact  that 
practitioners  have  frequently  expressed  to  me  a  desire  to 
possess  some  concise  work,  which  would  serve  as  a  guide  in 
determining  the  necessity  for  surgical  intervention  in 
diseases  of  the  internal  organs. 

I  have  written  essentially  for  the  practitioner.  I  have, 
therefore,  avoided  all  prolix  discussion,  and  confined  myself 
to  the  consideration  of  the  questions  indicated  by  the 
special  design  of  the  work.  On  the  advice  of  colleagues, 
whom  I  have  consulted,  I  have  included  in  each  chapter 
some  remarks  on  etiology,  pathological  anatomy,  clinical 
course,  diagnosis,  and  differential  diagnosis,  with  a  view 
to  enabling  the  practitioner  to  quickly  obtain  a  general 
grasp  of  the  condition  under  consideration.  These  para- 
graphs are,  however,  subordinate  to  the  main  purpose  of  my 
undertaking,  that  of  enabling  medical  men,  who  are  not  in 
hospital  practice,  to  arrive  at  an  independent  opinion  on  the 
advisability  of  operation  in  cases  of  internal  lesion.  I  do 
not  claim,  however,  to  have  given  separate  consideration 
to  all  the  internal  affections  which  have  been  submitted  to 
operation  from  time  to  time. 

To  avoid  misconception,  it  must  be  stated,  that  the 
references  to  literature  at  the  end  of  each  chapter  are  given 
only  with  the  idea  of  assisting  the  reader  to  consult  the 
authorities  quoted  ;  in  many  instances  articles  equal  in 
importance  to  those  cited  are  omitted  for  want  of  space. 

The  reader  must  not  entertain  the  idea  that  this  is  a  mere 
compilation.      Many  years'  work  in   hospital  and  private 


X  PREFACE. 

practice  have  given  me  the  opportunity  of  acquiring  a  large 
experience  in  the  questions  which  are  discussed  in  this  book, 
and  on  this  experience  I  have  largely  drawn  in  writing  it. 
There  should  be  some  advantage  in  the  circumstance,  that 
a  Physician  who  is  in  full  sympathy  with  the  standpoint  of 
the  Surgeon,  here  presents  to  the  Practitioner  a  discussion 
of  the  question  of  surgical  intervention. 

Hermann  Schlesinger. 

Vienna. 


CONTENTS, 


CHAPTER   I. 

DISEASES     OF     THE     BRAIN     AND     ITS     MENINGES. 

TUMOURS  OF  THE  BRAIN CEREBRAL  ABSCESS SINUS  THROMBOSIS 

AND       SINUS       PHLEBITIS    HYDROCEPHALUS    EPILEPSY    

CEREBRAL     PALSY     OF     CHILDREN CEREBRAL     HEMORRHAGE 

TUBERCULAR   MENINGITIS ACUTE    LEPTOMENINGITIS  -  pp.     1-39 

CHAPTER    II. 
DISEASES    OF    THE    SPINAL    COLUMN    AND    CORD. 

TUBERCULAR       SPONDYLITIS        (POTT's       DISEASE) OSTEOMYELITIS 

OF    THE    VERTEBRA TRAUMATIC     AFFECTIONS     OF     THE     SPINAL 

CORD TUMOURS    OF    THE    SPINAL   CORD ACUTE    POLIOMYELITIS 

pp.    41—60 

CHAPTER   III. 

DISEASES     OF     THE    PERIPHERAL    NERVES. 

NEURALGIA    OF    THE    FIFTH    CRANIAL    NERVE   (TIC    DOULOUREUX) 

OCCIPITAL      NEURALGIA BRACHIAL      NEURALGIA INTERCOSTAL 

NEURALGIA MERALGIA      PARAESTHETICA      (ROTH-BERNHARDT)— 

SCIATICA FACIAL       SPASM  SPASM        OF       CERVICAL        MUSCLES 

(SPASMODIC  TORTICOLLIS) PERFORATING  ULCER  OF  THE  FOOT     pp.   61-77 

CHAPTER   IV. 
NEUROSES. 

EXOPHTHALMIC    GOITRE INTERMITTENT    HYDRARTHROSIS  pp.     79-85 

CHAPTER   V. 
DISEASES     OF    THE    LARYNX. 

STENOSIS    OF    THE    LARYNX LARYNGEAL    PARALYSIS    OF    NERVOUS 

ORIGIN DIPHTHERIA  -----  pp.    87-95 


xii  CONTENTS. 

CHAPTER    VI. 

DISEASES    OF    THE    BRONCHI    AND    THE    LUNGS. 

BRONCHIECTASIS GANGRENE      OF     THE      LUNG ABSCESS      OF     THE 

LUNG PULMONARY      TUBERCULOSIS HYDATID      CYST      OF      THE 

LUNG ACTINOMYCOSIS   OF   THE   LUNG         -  -  .  pp_     97-II3 

CHAPTER   VII . 

DISEASES    OF    THE     PLEURA. 

PLEURISY     AND      EMPYEMA PNEUMOTHORAX H  YDROTHORAX 

TUMOURS   OF   THE   PLEURA  -  -  .  .  pp_     115-129 

CHAPTER   VIII. 

DISEASES    OF    THE    MEDIASTINUM. 

SUPPURATIVE    MEDIASTINITIS MEDIASTINAL    TUMOURS  -  pp.     I  3  I-I  37 

CHAPTER   IX. 
DISEASES    OF    THE    HEART    AND    BLOOD-VESSELS. 

PERICARDITIS ANEURYSM HYDROPS    ANASARCA     -  -  pp.     I39-I49 

CHAPTER  X. 
INDICATIONS     FOR     VENESECTION. 

INTOXICATIONS INSOLATION URAEMIA ECLAMPSIA PNEU- 
MONIA  CIRCULATORY    DISTURBANCE CHLOROSIS  -  pp      I  5  I-I  55 

CHAPTER  XI. 
DISEASES     OF    THE    MOUTH    AND    PHARYNX. 

HYPERTROPHY     OF     THE     TONSILS SEPTIC     PHARYNGITIS RETRO- 
PHARYNGEAL ABSCESS  AND  RETROPHARYNGEAL  CELLULITIS       pp.    157-163 

CHAPTER  XII. 
DISEASES    OF    THE    CESOPHAGUS. 

FUSIFORM     DILATATION     OF     THE     CESOPHAGUS DIVERTICULUM     OF 

THE     CESOPHAGUS CESOPHAGEAL     STENOSIS  :      CICATRICIAL     AND 

CARCINOMATOUS  ..-.-.  pp_     1 65-1 73 


CONTENTS.  xiii 

CHAPTER  XIII. 

DISEASES     OF    THE    STOMACH. 

GASTRIC    ULCER CARCINOMA    OF  THE   STOMACH SJMPLE  TUMOURS 

AND      FOREIGN-BODY      TUMOURS      OF      THE      STOMACH — PYLORIC 

STENOSIS,    GASTRIC    DILATATION,    AND    HOUR-GLASS    STOMACH 

CONGENITAL    HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS  pp.     I7S-I97 

CHAPTER  XIV. 
DISEASES    OF   THE   INTESTINES. 

DUODENAL  ULCER DUODENAL  STENOSIS INTESTINAL  TUBERCU- 
LOSIS  ACTINOMYCOSIS  OF  THE  INTESTINE CHRONIC  DYSEN- 
TERY AND  ULCERATIVE  COLITIS MUCOUS  COLITIS  AND  MEM- 
BRANOUS     ENTERITIS EMBOLUS       AND      THROMBOSIS       OF       THE 

MESENTERIC     VESSELS HEMORRHOIDS PROCTITIS  -  pp.     I99-223 

CHAPTER  XV. 

DISEASES     OF    THE    INTESTINES— coM^^mwe^. 

INTESTINAL       STRICTURE INTESTINAL       OBSTRUCTION INTUSSUS-  ' 

CEPTION INTESTINAL      CANCER CANCER       OF      THE      RECTUM 

CONGENITAL     DILATATION     OF    THE     COLON SUBCUTANEOUS    IN- 
JURIES  OF  THE   STOMACH   AND   INTESTINE APPENDICITIS  pp.    225—268 

CHAPTER    XVI. 

-DISEASES     OF    THE     PERITONEUM. 

ACUTE       CIRCUMSCRIBED       PERITONITIS DIFFUSE       PERITONITIS 

CHRONIC    EXUDATIVE    PERITONITIS CHRONIC    INDURATIVE    AND 

ADHESIVE    PERITONITIS TUBERCULAR    PERITONITIS  -  pp.     269-29  I 

CHAPTER    XVII. 

DISEASES    OF    THE     PERlT01<iElJM—conimued. 

TUMOURS     OF     THE     PERITONEUM,      OMENTUM     AND     MESENTERY 

ASCITES SUBPHRENIC    ABSCESS  .  .  -  pp_     293-304 

CHAPTER    XVIII. 
DISEASES    OF    THE    GALL-BLADDER    AND    BILE-DUCTS. 

CHOLELITHIASIS   (GALL-STONES) HYDROPS    OF  THE  GALL-BLADDER 

CHOLECYSTITIS:  EMPYEMA      OF      THE        GALL-BLADDER 

INTESTINAL     OBSTRUCTION       BY       GALL-STONE — CARCINOMA      OF 

JHE   GALL-BLADDER  ...  -  -  pp.    305-327 


xiv  CONTENTS. 

CHAPTER    XIX. 

DISEASES    OF    THE    LIVER. 

TUMOURS   OF  THE   LIVER HYDATID    CYST   OF  THE   LIVER ABSCESS 

OF   THE   LIVER ATROPHIC    CIRRHOSIS    OF    THE    LIVER MOVABLE 

LIVER THE    CONSTRICTED    LIVER  -  -  -  pp.     329-35O 

CHAPTER  XX. 

DISEASES     OF    THE     SPLEEN. 

TUMOURS    AND    CHRONIC    HYPERPLASIA    OF    THE    SPLEEN BANTl'S 

DISEASE FLOATING       SPLEEN RUPTURE       OF       THE       SPLEEN 

ABSCESS   OF  THE  SPLEEN  .  .  .  .  pp_     35I-365 

CHAPTER    XXI. 
DISEASES     OF     THE     PANCREAS. 

INFLAMMATION         AND  NECROSIS  PANCREATIC  CALCULUS  

PANCREATIC   CYSTS SOLID   TUMOURS   OF  THE   PANCREAS   -  pp.     367-379 

CHAPTER    XXII. 

DISEASES    OF    THE    KIDNEY    AND    RENAL    PELVIS. 

BRIGHT'S       disease RENAL       NEURALGIA       (NEPHRALGIA       H^MA- 

TURICA,      ANGIONEUROTIC      HEMATURIA) RENAL       CALCULUS 

RENAL    CONTUSIONS MOVABLE    KIDNEY  -  -  pp.     38  I-4O5 

CHAPTER    XXIII . 

DISEASES    OF   THE    KIDNEY   AND    RENAL    V'E'LYIS— continued. 

TUMOURS    OF    THE    KIDNEY CYSTIC    KIDNEY HYDATID    CYST    OF 

THE     KIDNEY HYDRONEPHROSIS     AND     PYONEPHROSIS TUBER- 
CULOSIS      OF       THE       KIDNEY  PYELITIS       AND         SUPPURATIVE 

NEPHRITIS PERINEPHRITIS  .  -  -  -  pp.    407-437 

CHAPTER    XXIV. 

DISEASES     OF    THE    BLADDER. 

CYSTITIS NOCTURNAL  ENURESIS TUBERCULOSIS  OF  THE   BLADDER 

pp.    439-446 

CHAPTER    XXV. 
DISEASES    OF    THE    JOINTS    AND    BONES. 

THE    NERVOUS    ARTHROPATHIES ARTHRITIS    DEFORMANS OSTEOMALACIA 

pp.    447-456 


CONTENTS.  XV 

APPENDIX  I. 

INDICATIONS     FOR     THE     INDUCTION     OF     PRExMATURE 
LABOUR. 

CARDIAC      DISEASE DISEASES     OF      THE      RESPIRATORY     ORGANS 

DISEASES    OF    THE    BLOOD THE    INFECTIOUS    FEVERS — DISEASES 

OF     THE     KIDNEY,     ECLAMPSIA DISEASES     OF     THE     STOMACH 

APPENDICITIS DISEASES     OF     THE     LIVER DISEASES     OF     THE 

NERVOUS    SYSTEM  -  -'  -  -  -  pp.    459-472 

APPENDIX  II. 

OPERATIONS    ON   DIABETICS.  pp.  473-476 

APPENDIX  III. 

THE     GENERAL    INFLUENCE    OF    OPERATIONS     ON 
THE     BODY. 

POST-OPERATIVE        PSYCHIC        DISTURBANCES  SHOCK,        PNEUMO- 
THORAX    THE       EFFECTS       OF       OPENING     THE     ABDOMEN,    THE 

CRANIUM       AND      THE      SPINAL      CANAL THE      EXTIRPATION      OF 

GLANDULAR        ORGANS ANESTHETICS THE         INFLUENCE         OF 

CERTAIN     DISEASES     ON     THE     INDICATIONS      FOR      OPERATION 

IMPORTANT    COMPLICATIONS    AFTER    OPERATION    -  -  pp.     477— 49O 

INDEX       -.--.-.       pp,  491-498 


CHAPTER    I. 

Diseases   of  the    Brain    and   its   Meninges. 


INDICATIONS    FOR    OPERATION. 


Chapter  I. 
DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES. 

TUMOURS   OF    THE   BRAIN. 

Etiology. — Of  greatest  importance  in  determining  the 
etiology  of  brain  tumours  are  the  presence  of  primary  new 
growths  in  other  parts  of  the  body,  and  the  discovery  of 
syphihtic  lesions  in  the  skin,  mucous  membranes,  or  some 
other  locality.  The  existence  of  tuberculosis,  especially  in 
the  lungs,  a  history  of  severe  trauma  to  the  head  preceding 
the  cerebral  symptoms,  the  discovery  of  the  cysticercus  or 
of  a  hydatid  cyst  in  some  organ,  are  all  likew^ise  etiologically 
significant. 

Pathological  Anatomy. — Brain  tumours  may  be 
primary  or  secondary.  Surgical  treatment  concerns  itself 
of  course  with  the  primary  growths  only.  One  of  the  most 
common  types,  the  glioma  or  gliosarcoma,  occurs  primarily 
only  in  the  brain  ;  sarcomata  may  be  primary  or  secondary. 
Cerebral  tuberculosis  is  almost  always  associated  with 
tuberculosis  elsewhere  ;  the  gumma  usually  co-exists  with 
syphilitic  changes  in  the  meninges.  Carcinoma  occurs  only 
as  a  metastasis,  and  is  not  infrequently  multiple  ;  the 
latter  is  true  also  of  tuberculosis  and  gumma,  whereas  the 
sarcoma  and  the  glioma  are  usually  solitary.  Sarcomata 
usually  show  a  sharp  differentiation  from  the  surroundmg 
brain  tissue,  and  tubercular  lesions  are  also  commonly 
circumscribed,  but  the  gumma  is  seldom  well  defined,  and 
the  glioma  diffusely  infiltrates  the  surrounding  brain  sub- 
stance. Not  infrequently  gummata  originating  in  the 
meninges  make  their  way  into  the  brain  substance  in  such  a 
manner  that  they  appear  to  have  started  in  the  latter. 
There  is  rarely  any  true  extension  of  meningeal  tumours 
into  the  brain  substance,  and  still  less  frequently  does  this 


4  INDICATIONS    FOR    OPERATION    IN 

occur  in  the  case  of  tumours  originating  in  the  cranial  bones. 
These  latter  are  often  metastatic  in  origin,  secondary  to 
sarcomata  and  carcinomata  of  the  thyroid,  mamma,  adrenal, 
prostate,  or  ovary,  and  sometimes  attain  to  very  large  pro- 
portions.    The  sarcomata  are  often  remarkably  vascular. 

With  regard  to  situation,  the  cerebral  hemispheres  are  most 
commonly  the  seat  of  new  growths,  next  the  cerebellum 
and  the  pons.  Solitary  tubercular  lesions  occur  character- 
istically in  the  two  latter  situations,  while  the  glioma  is 
most  frequent  in  the  brain. 

Tumours  of  the  posterior  cranial  fossa  are  often  associated 
with  the  development  of  pronounced  internal  hydrocephalus. 
Sometimes  the  surrounding  brain  substance  is  markedly 
altered  in  contour  by  the  compression  of  a  new  growth,  and 
softening  often  occurs.  Cranial  nerves  may  be  compressed 
and  destroyed.  The  cranial  bones  are  frequently  thinned  ; 
in  two  cases  under  my  own  observation,  however,  the 
calvarium  over  the  tumour  was  enormously  thickened. 

Clinical  Course. — The  symptoms  of  brain  tumour  fall 
into  two  categories,  the  general  and  the  localizing.  Of  the 
first,  the  most  constant  and  important  are  intense  headache 
and  the  presence  of  double  optic  neuritis.  Symptoms  of 
importance,  but  less  constant  than  the  above,  are  drowsiness, 
intellectual  dullness  (a  striking  delay  in  answering  questions), 
general  convulsions,  vertigo,  vomiting,  a  slow  pulse,  and 
transitory  loss  of  consciousness. 

In  many  cases  these  general  symptoms  are  the  only  ones 
present  ;  but  in  others  there  are,  in  addition,  signs  which 
are  characteristic  of  the  situation  of  the  lesion.  Such 
phenomena  may  be  due  to  a  lesion  directly  provoked  by 
the  growth  in  a  certain  area,  or  by  the  influence  of  the 
tumour  on  its  immediate  surroundings  (the  "  vicinity  " 
symptoms  of  Oppenheim  and  Bruns),  or  by  its  effect  on 
more  distant  regions  of  the  brain.  Occasionally  the  site  is 
revealed  by  a  definitely  localized  tenderness  on  skull 
percussion. 

Characteristic  focal  symptoms  are  found  when  the  tumour 
is  situated  in  the  Rolandic  region.  In  such  cases  typical 
attacks  of  motor  Jacksonian  epilepsy  may  occur  (p.  28), 
preceded  frequently  by  attacks  of  sensory  cortical  epilepsy 
affecting  the  same  area  in  which  the  motor  convulsions  later 
appear.     In  the  early  stages  transitory  paralytic  symptoms 


DISEASES   OF   THE   BRAIN  AND    ITS   MENINGES.     5 

are  present  ;  in  the  later  stages  they  become  persistent. 
Often  at  the  beginning  they  are  of  a  monoplegia  type, 
becoming  hemiplegia  in  course  of  time.  The  convulsions 
occur  first  in  the  paralytic  muscles  ;  the  senses  of  touch  and 
of  position  are  frequently  much  interfered  with  in  the 
paralysed  areas. 

The  tumours  of  the  third  left  frontal  convolution  give  rise 
to  a  motor  aphasia  which  declares  itself  early,  but  becomes 
complete  only  by  slow  degrees.  Tumours  of  the  other 
parts  of  the  frontal  lobes  present  no  such  characteristic 
symptoms,  but  a  diagnosis  may  sometimes  be  arrived  at  ; 
frequently  an  unsteadiness  of  gait  is  present,  resembling  the 
ataxia  of  cerebellar  disease  (Bruns).  The  intellectual  powers 
are  often  markedly  dull.  Optic  neuritis  is  frequently  a  late 
symptom  and  not  uncommonly  unilateral.  In  some  cases 
there  is  localized  percussion  tenderness,  and,  according  to 
Bruns,  a  tympanitic  note  may  be  elicited  over  the  affected 
area.  The  diagnosis  of  frontal  tumour  is  further  confirmed 
when,  following  on  the  above  symptoms,  or  of  hemi-  or 
monoparesis,  there  supervene,  in  later  stages,  signs  of 
general  feebleness  of  the  trunk  muscles,  or  of  cortical 
epilepsy,  or  deviation  of  the  head  to  one  side  with  rigidity 
of  the  neck  and  conjugate  deviation  of  the  eyes. 

Growths  of  the  left  temporal  lobe  are  often  associated 
with  sensory  aphasia  (this  appears  in  the  case  of  tumours 
of  the  right  temporal  lobe  when  the  subject  is  left-handed)  ; 
sometimes  convulsions  are  in  such  a  case  preceded  by  aural 
premonitory  symptoms.  In  the  late  stages  hemianopsia, 
hemiansesthesia,  and  hemiparesis  are  sometimes  found. 

A  tumour  of  the  occipital  lobe  may,  in  addition  to  the 
general  symptoms,  give  rise  to  a  crossed  hemianopsia,  with 
absence  of  the  hemiopic  pupil  reaction.  The  diagnosis 
obtains  confirmation  if  symptoms  of  ocular  irritation  and 
psychic  phenomena  appear.  The  presence  of  hemianopsia, 
alexia,  and  optic  aphasia  in  combination  point,  according 
to  Bruns,  to  a  lesion  of  the  left  occipital  lobe.  A  bilateral 
lesion  of  the  occipital  lobes  gives  rise  to  general  mental 
dullness. 

Tumours  of  the  superior  parietal  lobule  often  occasion 
defects  of  sensibility,  notably  of  the  sense  of  position  and  of 
the  stereognostic  sense  ;  these  may  be  associated  with 
ataxia,  which  is  in  this  case  probably  a  direct  result  of  the 


6  INDICATIONS    FOR    OPERATION    IN 

lesion  (Oppenheim).  Signs  of  motor  irritation  and  paralysis 
are  not  uncommon.  Deep-seated  tumours  of  the  inferior 
parietal  lobe  may  occasion  hemianopsia  ;  alexia  and  optic 
aphasia  are  only  associated  with  such  growths  when  they 
are  left-sided. 

Tumours  of  the  cerebellum  give  rise  directly  only  to  the 
two  symptoms  ataxia  and  vertigo.  Symptoms  due  to 
compression  of  the  surrounding  parts  are  usually  absent 
when  such  growths  are  situated  dorsally,  but  are  common 
in  basal  tumours.  When  they  occasion  unilateral  paralysis 
of  the  fifth  to  the  twelfth  cranial  nerves  the  tumour  is 
usually  to  be  found  on  the  same  side  as  the  paralysis  ;  and 
the  same  holds  for  the  associated  paralysis  of  the  abducens. 
Signs  of  cerebral  compression  appear  early,  and  convulsions 
with  opisthotonus  are  frequent  (Oppenheim). 

Diagnosis. — The  diagnosis  of  a  cerebral  tumour  can  be 
established  in  the  majority  of  cases.  Severe  persistent 
headache  which  resists  treatment  is  always  suspicious.  If 
with  this  there  co-exist  double  optic  neuritis,  dulling  of  the 
intellect,  and  vomiting  during  the  height  of  the  attack,  then 
the  presence  of  tumour  is  very  probable.  Certain  other 
general  s\^mptoms  assist  in  arriving  at  a  correct  opinion — 
vertigo,  slowness  of  the  pulse,  alterations  in  the  urinary 
secretion,  and  epileptiform  attacks,  particularly  if  there  is 
a  steady  increase  in  their  severity,  and  if  attacks  become 
gradually  more  frequent.* 

The  diagnosis  of  situation  is  more  readily  made  when 
progressive  focal  signs  have  been  present  for  a  considerable 
period.  If  optic  neuritis  is  absent,  its  appearance  must 
usually  be  awaited  before  a  positive  diagnosis  is  possible. 
A  fact  of  practical  importance  is,  that  signs  of  irritation  and 
paralysis  referable  to  lesions  of  the  Rolandic  region  are 
usually  due  to  tumour.  The  onset  of  general  symptoms 
is  to  be  expected  later  in  the  case  of  growths  of  this  region 
than  elsewhere,  and  consequently  the  less  importance  is  to 
be  attached  to  their  absence  (Bruns).  With  regard  to  the 
diagnosis  of  tumour  in  other  situations,  reliance  must  be 


*  Sometimes  the  disease  shows  itself  abruptly  in  a  condition  of  other- 
wise good  health ;  such  an  onset  has  several  times  come  under  my  own 
observation.  In  two  such  cases  the  tumour  made  its  way  outwards  and 
was  palpable  under  the  scalp. 


DISEASES   OF    THE   BRAIN  AND   ITS   MENINGES.     7 

placed  on  the  above  described  symptoms,  always  remem- 
bering that  only  well  developed  symptoms  should  be  relied 
on  ;  the  successive  development  of  phenomena  must  also 
be  carefully  studied,  and  the  local  signs  on  the  skull  must 
be  compared  with  those  other  which  appear  to  indicate  the 
site  of  the  growth. 

Further  mention  must  be  made  of  these  cranial  indica- 
tions. The  most  important  are,  strictly  localized  headache 
corresponding  with  defined  tenderness  to  percussion,  the 
occurrence  of  tumour-like  protrusion  of  the  skull,  and  the 
presence  of  the  cracked-pot  sound.  This  last  sign,  whose 
importance  has  been  lately  emphasized  by  several  competent 
observers  (Macewen,  Bruns,  Oppenheim),  is  more  frequently 
present  in  children.  In  adults  I  have  failed  to  find  it  in 
twenty  cases  ;  if  it  is  present,  and  corresponds  with  other 
focal  signs,  it  is  of  great  importance.  In  several  cases 
circumscribed  tenderness  to  percussion  has  enabled  a 
diagnosis  to  be  made  at  an  early  stage.  If  the  skull  is 
eroded  by  the  tumour,  and  the  latter  presents  as  a  palpable 
fluctuating  swelling  (as  especially  occurs  in  cases  of 
hydatid  cyst),  a  diagnosis  of  situation  can,  of  course,  be 
made  at  once. 

This  apparently  definite  local  sign,  the  erosion  of  the 
skull,  may,  however,  occasionally  give  rise  to  some  confusion 
in  diagnosis,  for  a  bone  tumour  may  co-exist  with  and  even 
correspond  in  position  with  a  cerebral  tumour  beneath,  or  a 
growth  of  the  dura  may  exhibit  a  similar  relationship.  Two 
such  cases  have  come  under  my  own  observation.  The  first 
was  that  of  a  woman,  aged  52,  who  came  into  hospital  in  a 
condition  of  marked  stupor,  with  complaint  of  only  occasional 
headache,  no  convulsions,  and  normal  pulse.  There  was 
slight  exaggeration  of  the  tendon  reflexes  on  the  right  side, 
but  no  motor  or  obvious  sensory  disturbances,  and  the 
cranial  nerves  were  normal.  Immediately  before  death  the 
left  optic  disc  was  blurred,  and  for  a  few  days  before  this  a 
rapidly  progressive  hemiparesis  of  the  right  side  of  the  body 
made  its  appearance.  Six  years  before,  a  recurrent  fibro- 
sarcoma of  the  abdominal  wall  had  been  removed,  and,  in 
view  of  this,  great  importance  was  attached  to  the  presence 
of  a  tumour  situated  in  front  of  and  above  the  left  ear,  of 
bony  consistence  and  the  size  of  half  a  plum-stone  ;  this 
was  looked  upon  as  a  bony  metastasis  pressing  on  the  frontal 


8  INDICATIONS    FOR    OPERATION    IN 

lobe.  The  general  condition  of  the  patient  precluded 
surgical  treatment.  At  the  necropsy  a  large  sarcoma  of  the 
frontal  lobe  was  found,  and,  situated  exactly  over  but  quite 
distinct  from  this,  an  exostosis  of  the  skull. 

The  second  case  was  a  man,  aged  26,  complaining  of  severe 
occipital  headache,  excessive  rigidity  of  the  neck,  and 
frequent  vomiting.  From  time  to  time  he  had  attacks  of 
stupor,  and  tonic  contractions  of  the  muscles  generally, 
with  opisthotonus.  The  cranial  nerves  were  unaffected, 
except  the  left  hypoglossal  (deviation  of  the  tongue  to 
the  left)  and  the  optic.  As  far  as  could  be  ascertained  there 
was  left  homonomous  hemianopsia.  At  the  upper  part  of 
the  occipital  bone  on  the  right  side  there  was  a  large  flattened 
protrusion  very  sensitive  to  pressure.  Double  optic  neuritis 
rapidly  progressed  to  atrophy.  The  diagnosis  was  made  of 
tumour  of  the  bone  or  dura  over  the  right  occipital  lobe. 
Death  occurred  suddenly.  The  necropsy  demonstrated  an 
endothelioma  of  the  dura  mater  over  the  right  occipital  lobe, 
with  pronounced  erosion  of  the  skull,  and,  in  addition, 
a  large  glioma  of  the  right  occipital  lobe  with  a  recent 
haemorrhage  into  it. 

The  discovery  of  a  vascular  bruit  will  lead  to  the  diagnosis 
of  aneurysm,  or  of  a  highly  vascular  growth  (sarcoma)  ;  the 
co-existence  of  tuberculosis,  of  syphilitic  lesions,  of  a  primary 
malignant  growth,  or  of  the  echinococcus  or  cysticercus 
elsewhere,  will  indicate  the  probable  nature  of  the  intra- 
cranial lesion. 

Differential  Diagnosis. — So  long  as  a  tumour  gives  rise  to 
general  symptoms  only,  there  is  considerable  probability  of 
its  being  confused  with  other  morbid  conditions.  Optic 
neuritis  narrows  the  limits  of  possible  error,  and  if  this 
co-exist  with  persistent  headache  and  stupor,  these  limits 
are  further  circumscribed.  Sometimes  the  differentiation 
from  cerebral  abscess  (p.  17)  is  very  difficult.  In  addition 
to  what  is  said  on  the  subject  elsewhere,  abscess  sometimes, 
in  my  experience,  gives  rise  to  optic  neuritis  in  its  early 
stages.     This  is,  however,  undoubtedly  exceptional. 

Fever  is  not  an  exclusive  sign  of  abscess  ;  it  may  also 
exist  in  cases  of  tumour  (in  tuberculosis,  more  rarely  in 
carcinoma),  especially  in  children  with  tubercular  lesions 
elsewhere.  In  a  case  which  was  for  several  weeks  under  my 
observation,  and  in  which  an  affection  of  the  frontal  lobe 


DISEASES    OF    THE   BRAIN   AND    ITS    MENINGES.     9 

was  suspected,  irregular  fever  was  present  for  some  weeks. 
At  the  autopsy  a  diffuse  glioma  infiltrating  the  convolutions 
of  the  right  frontal  lobe  was  discovered.  A  most  careful 
examination,  carried  out  by  Prof.  Weichselbaum,  failed  to 
reveal  any  other  lesion  to  account  for  the  fever. 

More  rarely  there  arises  a  difficulty  in  differentiating 
between  tumour  and  sinus  thrombosis  (q.v.). 

Oppenheim  has  rightly  remarked  that  the  differential 
diagnosis  between  tumour  and  acquired  hydrocephalus  can 
hardly  ever  be  made  with  certainty,  especially  as  the  latter 
affection  very  often  complicates  tumour.  He  has  enunciated 
the  following  points  in  favour  of  hydrocephalus  :  the 
characteristic  hydrocephalic  shape  of  the  skull,  a  duration 
of  several  years,  and  the  absence  of  well-marked  focal 
symptoms. 

Of  greater  practical  importance  is  the  probability  of 
confusion  with  general  paralysis,  especially  when  the  latter 
exhibits  in  its  early  stages  the  characters  of  cortical 
epilepsy.  Optic  neuritis  will  exclude  general  paralysis,  and 
complete  reflex  immobility  of  the  pupil  is  rarely  present 
except  in  cases  of  tumour.  In  the  late  stages  of  tumour,  and 
especially  of  multiple  tumours,  the  symptoms  may  closely 
resemble  those  of  general  paralysis.  I  have  seen  a  case  of 
cerebral  tumour,  operated  on  with  good  result,  which  had 
been  diagnosed  as  general  paralysis  by  several  distinguished 
physicians.  The  examination  of  the  fundus  oculi  revealed 
the  presence  of  optic  neuritis,  and  this  led  to  a  correct 
diagnosis. 

When  a  tumour  is  associated  with  convulsions  at  an 
early  stage,  a  differential  diagnosis  from  ordinary  epilepsy 
has  to  be  made  ;  the  presence  of  other  symptoms  will 
facilitate  this,  in  particular  optic  neuritis,  which  is  not  found 
in  ordinary  epilepsy.  The  phenomena  of  Jacksonian 
epilepsy  which  is  not  caused  by  tumour  (e.g.,  that  due  to 
softening  or  scar  formation),  do  not  show,  as  a  rule,  the 
tendency  to  progression  which  is  found  in  tumour. 

Uraemia  may  give  rise  to  symptoms  resembling  those  of 
cerebral  growth.  Headache,  vomiting,  slowness  of  pulse 
occur  in  the  course  of  both  affections,  and  renal  disease  may 
give  rise  to  optic  neuritis,  with  swelling  of  the  disc.  On  the 
other  hand,  a  brain  tumour  may  cause  albuminuria.  The 
presence  of  renal  epithelium  in  the  urine  will  always  point 


lo  INDICATIONS    FOR    OPERATION    IN 

to  the  probability  of  uraemia,  although  the  possibility  of 
the  simultaneous  development  of  a  renal  inflammation  and 
a  cerebral  tumour  must  be  borne  in  mind,  and  has  occurred 
in  several  instances  which  have  been  under  my  observation. 
Multiple  sclerosis  is  rarely  likely  to  be  confused  with  tumour ; 
it  is  distinguished  from  the  latter  by  the  absence  of  optic 
neuritis,  persistent  headache  and  stupor,  by  the  absence  of 
percussion-tenderness  of  the  skull,  and  by  the  presence  of 
definite  spinal  phenomena. 

INDICATIONS  FOR  OPERATION. 

Operation  may  be  undertaken  : — 

1.  For  the  radical  extirpation  of  the  growth. 

2.  For  the  relief  of  symptoms  by  some  palliative  procedure. 
Indications    for    extirpation    are     met    with    only   in    a 

restricted  number  of  cases.  They  may  be  said  to  be  present 
when  the  diagnosis  of  tumour  is  definite,  when  localization 
is  possible,  and  the  tumour  is  in  a  situation  accessible  to  the 
knife.  Eradication  is  possible  when  the  tumour  is  circum- 
scribed and  of  moderate  dimensions.  With  regard  to  acces- 
sibility, Bruns  has  placed  the  different  parts  of  the  brain  in 
the  following  order  :  (i)  The  Rolandic  region  ;  (2)  The  speech 
centres  ;  (3)  The  frontal  lobes  ;  (4)  The  occipital  lobes  ;  (5) 
The  temporal  lobes.  These  are  also  the  areas,  lesions  of  which 
may  be  diagnosed  earliest  and  most  definitely,  and  when 
the  signs  of  tumour  are  clear  the  prognosis  of  operation  is 
relatively  good.  With  regard  to  tumours  of  the  cerebellum, 
although  they  are  often  accessible,  the  results  of  operations 
for  their  removal  have  been  hitherto  so  bad  that  one  is 
forced  to  agree  with  Oppenheim  and  Bruns,  that  operation 
is  not  advisable  in  most  cases.  Operation  is  also  inadvisable 
when  the  tumour  is  situated  in  other  situations  than  those 
enumerated  above,  and  at  the  base  ;  the  prognosis  quoad 
vitam  is,  at  present  at  any  rate,  most  unfavourable.  It  is 
usually  impossible  to  be  sure  beforehand  whether  a  tumour 
has  originated  in  brain,  meninges,  or  bone  ;  from  the  point 
of  view  of  operation  this  point  is  unimportant,  if  its 
situation  as  regards  the  brain  can  be  definitely  ascertained, 
nor  will  a  supposed  subcortical  position  of  the  tumour  in 
the  regions  mentioned  alter  the  indications  for  operative 
interference. 

With  regard  to  the  diagnosis  of  the  nature  of  a  growth, 


DISEASES  OF   THE  BRAIN  AND   ITS   MENINGES,      ii 

and  the  bearing  of  this  diagnosis  on  operation,  the  following 
considerations  should  be  borne  in  mind.  When  tuberculosis 
is  discovered  in  some  other  organ  of  the  body,  and  pyrexia 
is  present,  the  cerebral  tumour  is  probably  also  tubercular  ; 
as  a  rule,  however,  tubercular  foci  are  not  single,  and  some- 
times co-exist  with  diffuse  changes  in  the  meninges  and 
cord.  In  spite  of  the  latter  facts,  however,  my  own  expe- 
rience agrees  with  that  of  Kronlein  and  other  authors,  that 
under  certain  circumstances  brain  tubercle  ought  to  be 
operated  on  (a)  When  there  are  no  signs  of  widely  diffused 
tuberculosis  in  other  organs  and  the  general  condition  of 
the  patient  is  good,  and  when  the  pyrexia  is  not  high  ; 
{b)  When  symptoms  of  meningitis  and  spinal  disease  are 
absent  ;    (c)  When  the  symptoms  point  to  a  single  focus. 

If  the  symptoms  of  tumour  are  preceded  by  those  of 
syphilis,  if  tertiary  lesions  have  presented  themselves 
elsewhere  and  the  diagnosis  of  cerebral  gumma  is  practically 
certain,  surgical  measures  will  only  be  undertaken  under 
certain  conditions,  on  which  my  own  opinion  coincides  with 
that  of  Friedlander  ;  they  are  as  follows  ;  (i)  When  the 
symptoms  are  progressive  in  spite  of  energetic  specific 
treatment,  and  threaten  life  ;  (2)  When  the  tumour  remains 
stationary  after  a  course  of  treatment,  and  the  focus  is  easily 
accessible  and  to  all  appearance  of  small  dimensions  ;  (3) 
When  symptoms  of  Jacksonian  epilepsy  persist  after  the 
earlier  tumour  symptoms  have  disappeared.  Even  when 
these  conditions  are  present  operation  is  contra-indicated 
when  there  are  {a)  Signs  of  basal  or  advanced  spinal  syphilis  ; 
(b)  Pronounced  cachexia,  and  the  presence  of  amyloid  and 
other  serious  complications  in  internal  organs. 

When  the  diagnosis  of  a  metastatic  growth  is  made, 
operation  is  seldom  justified.  It  is  indicated  :  (i)  When 
the  primary  tumour  has  been  removed,  and  there  are  no 
clinical  signs  of  other  metastases  ;  (2)  When  the  symptoms 
give  cause  for  the  belief  that  the  brain  tumour  is  single  and 
situated  in  an  easily  accessible  region  ;  (3)  When  the  general 
condition  is  good. 

The  presence  of  multiple  growths,  when  this  is  known 
before  operation,  or  definitely  suggested  by  the  symptoms, 
is  an  absolute  contra-indication  to  radical  operation.  A 
diagnosis  of  multiple  tumour  must  not,  however,  be  founded 
on  a  discovery  that  the  disease  is  of  a  type  which  usually 


12  INDICATIONS    FOR    OPERATION    IN 

gives  rise  to  multiple  lesions  of  the  nervous  system  (tubercle, 
gumma,  cysticercus,  etc.). 

With  regard  to  the  size  of  a  tumour  there  are  rarely  exact 
data,  and  if  other  indications  for  operation  are  favourable, 
the  supposition  that  the  tumour  is  of  large  size  should  not 
be  allowed  to  weigh  against  them. 

The  earlier  operation  is  undertaken,  the  more  favourable 
are  the  chances  of  complete  extirpation.  This  consideration 
must  not,  however,  lead  one  to  recommend  operation  until 
a  definite  diagnosis  has  been  reached  ;  but,  as  soon  as  the 
general  and  local  diagnosis  of  a  cerebral  tumour  has  been  made, 
when  syphilis  and  tubercle  have  been  excluded,  and  when  the 
possibility  of  surgical  intervention  has  been  decided,  then 
operation  should  be  undertaken  without  delay. 

Palliative  operation  for  cerebral  tumour  is  indicated  in 
the  absence  of  focal  symptoms,  when  signs  of  cerebral  com- 
pression are  prominent,  and  the  latter  is  giving  rise  to 
insupportable  suffering.  It  is  especially  indicated  when 
the  patient  is  suffering  agonizing  headache,  and  when  an 
optic  neuritis  is  present  which  threatens  to  proceed  to 
atrophy  ;  in  several  cases  blindness  has  been  thereby 
averted.  Operation  is  also  called  for  in  the  presence  of 
frequent  general  convulsions. 

Such  palliative  operations  comprise  lumbar  puncture, 
and  opening  of  the  skull,  with  eventual  puncture  of  the 
ventricle.  We  have  now  a  considerable  number  of  observa- 
tions on  lumbar  puncture  in  cerebral  tumour,  which  go  to 
show  that  the  procedure  is  not  without  risk.  Lichtheim 
and  Fiirbringer  have  published  four  cases  of  death  following 
immediately  after  lumbar  puncture,  and  others  have  since 
been  reported.  I  have  had  a  similar  experience,  which  I 
related,  some  years  ago.  A  young  man,  with  signs  of 
tumour  in  the  occipital  lobe,  developed  symptoms  of  severe 
intracranial  pressure  (marked  slowing  of  the  pulse,  vomiting, 
agonizing  headache,  and  Cheyne-Stokes  respiration).  In- 
ternal medication  was  useless,  and  lumbar  puncture  was 
performed.  After  the  drawing  off  of  a  few  cc.  the  head- 
ache became  insupportable,  and  stupor  came  on,  followed 
by  convulsions.  He  died  twenty-four  hours  later.  The 
autopsy  revealed  a  recent  haemorrhage  into  a  glioma  of  the 
right  occipital  lobe. 

In  other  cases  (for  example  in  one  on  whom  I  performed 


DISEASES   OF   THE  BRAIN  AND   ITS   MENINGES.      13 

lumbar  puncture  four  times)  a  certain  amelioration  of  some 
of  the  symptoms  takes  place.  The  operation  is  indicated 
when  in  the  presence  of  symptoms  of  severe  intracranial 
pressure  trephining  is  refused,  and  when  optic  neuritis 
shows  signs  of  passing  into  atrophy.  If  there  are  indica- 
tions that  the  tumour  is  very  vascular,  lumbar  puncture 
is  contra-indicated.  It  must  be  performed  with  great 
care  ;  the  rapid  escape  of  fluid  must  be  prevented,  and 
the  operation  be  at  once  abandoned  :  (a)  If  the  pressure 
is  very  low  at  the  beginning,  or  rapidly  becomes  so  ;  (b) 
If  marked  embarrassment  of  circulation  and  respiration 
supervenes. 

Opening  the  skull  has  frequently  been  resorted  to  during 
the  last  few  years  for  the  relief  of  intracranial  pressure.  If 
the  brain  bulges  into  the  opening  and  so  prevents  the  free 
escape  of  fluid,  and  if  the  signs  of  compression  persist  (which 
may  not  always  be  the  case),  puncture  of  the  ventricle  is 
indicated  ;  by  this  means  even  well-established  focal  symp- 
toms due  to  inoperable  neoplasm  may  be  arrested.  I  am  able 
to  cite  a  very  instructive  case  illustrative  of  this  fact. 
A  young  man  developed  convulsions  of  the  type  of  cortical 
epilepsy  several  months  after  an  injury.  Under  treatment 
with  bromides  the  symptoms  disappeared  for  two  years. 
There  then  supervened  status  epilepticus,  stupor,  marked 
optic  neuritis,  severe  headache,  and  left  hemiplegia.  The 
skull  and  dura  were  opened  over  the  Rolandic  area,  and  a 
large  hernia  developed  here,  covered  only  by  the  soft  parts. 
Although  nothing  was  done  to  the  prolapse  the  paralysis 
improved  considerably,  the  convulsions  ceased,  and  the 
headache  and  optic  neuritis  disappeared.  The  patient  was 
able  to  resume  his  occupation  for  several  months.  His 
symptoms  reappeared  suddenly,  and  he  died  shortly  after- 
wards. Post  mortem  a  huge  gliosarcoma  was  found 
infiltrating  the  whole  of  the  right  hemisphere.  The  growth 
of  the  tumour  had  evidently  continued,  yet  after  the  opera- 
tion the  general  and  focal  symptoms  had  markedly  improved. 
{v.  Neurol.  Centralb.,  1895,  p.  702,  and  1898,  p.  974.) 

In  a  case  under  my  care  of  basal  tumour,  the  result 
was  disappointing.  The  skull  was  opened,  and  the  bone 
replaced;  the  latter  promptly  healed.  Neither  the  optic 
neuritis  nor  any  other  symptom  was  improved  by  the 
operation. 


14  INDICATIONS    FOR    OPERATION     IN 

Prognosis. — Regarding  the  prognosis  of  the  operation, 
the  numerous  ill-successes  of  recent  years  have  made  one 
more  circumspect.  About  6  per  cent  of  cases  fulfil  all  the 
conditions  for  direct  surgical  intervention,  but  in  3  to  4 
per  cent  only  is  complete  ablation  and  cure  achieved. 
Tumours  of  the  Rolandic  region  offer  the  best  prognosis, 
because  they  can  be  diagnosed  the  soonest  and  with  the 
greatest  certainty.  The  operative  treatment  of  tumours  in 
other  situations  is  attended  with  less  success,  and  the 
prognosis  of  operable  tumours  of  the  cerebellum  is  worst 
of  all. 

Operative  interference  may  be  directly  responsible  for 
death  ;  Oppenheim  placed  the  mortality  of  operation  at 
37'7  P^r  cent.  Again,  much  more  severe  symptoms  may 
follow  operation  than  those  which  the  tumour  gave  rise  to; 
in  particular,  more  extensive  paralysis.  In  one  of  my  own 
cases  a  complete  motor  aphasia  supervened,  which  disap- 
peared only  after  a  lapse  of  several  months  ;  another  case 
developed  marked  cortical  ataxia.  As  a  rule,  lesions  caused 
by  operation  reach  their  maximum  intensity  at  first,  and 
afterwards  gradually  improve.  A  steady  increase  in  the 
severity  of  symptoms  after  complete  extirpation,  such  as 
would  be  produced  by  encephalitis,  appears  to  have  very 
rarely  occurred.  The  possibility  that  the  operation  may 
give  rise  to  pronounced  paralysis  should  not  be  allowed  to 
influence  one  against  recommending  it,  for  the  tumour  itself 
is  a  definite  menace  to  life. 

The  prognosis  if  no  operation  is  undertaken. — If  in  the 
face  of  the  indications  which  have  been  given,  no  operation 
is  done,  internal  medication  offers  little  chance  of  success. 
Sometimes,  in  non-syphilitic  cases,  large  doses  of  potassium 
iodide  and  mercurial  injections  have  appeared  to  cause 
some  amelioration  of  symptoms  for  a  time,  but  complete 
cure  by  medical  treatment  is  a  very  rare  event.  Sponta- 
neous recovery  by  calcification  of  the  tumour  is  also  extremely 
unusual.  Death  is,  therefore,  to  be  expected  when  operation 
is  not  undertaken,  and  when  no  palliative  operation  is  done 
the  symptoms  will  show  steady  progression. 

Risks  of  operation  when  the  diagnosis  is  faulty. — Open- 
ing the  skull  is  not  an  operation  free  from  risk.  Fatal 
haemorrhage  from  the  diploic  vessels  has  been  recorded,  and 
traumatic  encephalitis  and  oedema  of  the  brain  may  occur. 


DISEASES  OF   THE  BRAIN  AND   ITS  MENINGES.     15 

Sometimes  a  persistent  hernia  develops,  or  Jacksonian 
epilepsy  from  meningeal  adhesions.  Opening  of  the  skull 
with  chisel  or  trephine  should,  therefore,  only  be  undertaken 
when  the  diagnosis  of  tumour  is  clear. 

LITERATURE. 

Oppenheim.  Hirntumoren.  Nothnagel's  Handbuch  d.  spez. 
Pathol.     2nd  Ed.,  Vienna,  1902. 

Bruns.     Geschwiilste  des  Nervensystems.     Berlin.      1897. 

Bergmann.  Die  Chirurgische  Behandlung  der  Hirnkrankheiten. 
3rd  Ed.,     Berlin,    1899. 

GowERS.     Diseases  of  the  Nervous  System. 

A.  Starr.     Tumours  of  the  Brain.     Med.  News,  June,   1886. 

Chipault.     Chirurgie  Oper.  du  Systeme  Nerveux.     Paris,   1895. 

A.  PiLCz.  Tumor  Cerebri  und  chir.  Eingriffe.  Centralb.  f.  d. 
Grenzgebiete  d.  Med.  u.  Chir.      1899. 

F.  ScHULTZE.  Zur  Diagnostik  u.  Chir.  Behandl.  d.  Hirntumoren. 
Dent.  Zeit.  f.  Nervenheilk.     Bd.  ix. 

Henschen.  Hirntumoren.  Handbuch  der  spez.  Therap.,  von 
Penzoldt-Stintzing.     3rd  Ed. 

Kronlein.  Dauerheilung  eine  Hirntuberkels.  Arch.  f.  klin. 
Chirurgie.     Bd.  Ixiv. 


CEREBRAL  ABSCESS. 

Etiology. — Cerebral  abscess  almost  always  occurs  as  a 
secondary  lesion.  The  most  important  etiological  factors 
are  :  (i)  Affections  of  the  ear  ;  (2)  Injuries  of  the  skull  ; 
(3)  Diseases  of  the  nose  ;  (4)  Metastatic  lesions  (especially 
following  putrid  affections  of  the  lungs  and  general  sepsis)  ; 
(5)  Chronic  cranial  suppurations.  The  first  two  of  these  are 
by  far  the  most  frequent.  Of  ear  affections,  those  in  question 
are  purulent  otitis  media  and  mastoid  disease. 

Pathological  Anatomy. — Cerebral  abscess  may  be  acute, 
subacute,  or  chronic  ;  as  a  rule  it  is  single  ;  metastatic 
abscesses  alone  are  wont  to  be  multiple.  The  acute  abscess 
originating  by  continuity  from  some  neighbouring  focus  is 
usually  superficial ;  the  chronic  abscess  usually  more  deeply 
situated.  With  regard  to  localization,  those  originating 
from  some  traumatic  lesion  usually  develop  superficially 
at  the  site  of  injury  ;  otogenic  abscesses  are  found  especially 
in  the  temporal  lobe  and  cerebellum  ;  the  rhinogenic  in  the 
frontal  lobes  ;  and  those  which  follow  bone  disease  usually 
in  the  immediate  vicinity  of  the  affected  bone.  These 
abscesses  may  reach  the  size  of  an  apple  or  larger.     The 


t6  indications    FOR    OPERATION    IN 

meninges  are  regularly  involved  in  traumatic  abscess,  and 
frequently  in  the  otitic.  In  the  ultra-acute  type  an  acute 
suppurative  cerebrospinal  meningitis  is  often  present  ;  in 
the  subacute  form  the  meningitis  is  usually  local,  with 
adhesions  to  the  brain  surface,  but  sometimes  there  is  a 
serous  meningitis  with  abundant  serous  exudate.  Otitic 
abscesses  are  sometimes  complicated  by  thrombosis  of  the 
lateral  sinus  and  extradural  abscess.  Old  standing  abscesses 
may  become  encapsuled  ;  they  may  extend  later  and  burst 
even  after  several  years'  duration. 

Clinical  Course. — An  abscess  may  run  a  latent  course 
throughout.  In  other  instances  symptoms  of  general  and  of 
cerebral  disturbance  are  present  :  headache,  vertigo,  local 
tenderness  of  the  skull,  stupor,  slowness  of  pulse,  convul- 
sions, and  delirium.  The  temperature  may  be  raised,  and 
frequently  there  are  rigors  ;  the  absence  of  fever  is,  how- 
ever, not  rare  (Macewen).  Optic  neuritis  i^  more  frequent, 
especially  in  the  subacute  cases,  than  was  at  one  time 
thought.  Of  the  focal  symptoms  (which  often  first  appear 
at  a  late  stage)  the  following  are  the  most  important  : 

In  temporal  abscess,  sensory  aphasia  and  double  hemi- 
anopsia of  the  same  side.  In  many  instances  (Oppenheim) 
as  a  characteristic  sign,  the  so-called  "  optic  aphasia  "  is 
present,  that  is  to  say,  the  patient  cannot  name  objects 
shown  to  him.  In  the  later  stages,  when  the  process 
advances  rapidly,  hemiparesis  of  the  opposite  side  of 
the  body  appears,  with  convulsions  of  the  character  of 
cortical  epilepsy. 

In  frontal  abscesses  there  are  often  no  localizing  signs, 
even  when  they  are  of  large  size.  Sometimes  there  is 
ataxia  resembling  that  of  cerebellar  disease,  and  certain 
peculiar  psychical  disorders.  In  the  late  stages  a  rapidly 
progressing  hemiplegia  of  the  opposite  side  appears.  Optic 
neuritis  often  appears  only  towards  the  end. 

Abscesses  of  the  motor  region  give  rise  to  paralysis,  often 
of  monoplegic  type,  and  attacks  of  cortical  epilepsy. 

In  cerebellar  abscesses  there  are  observed  sometimes  slight 
rigidity  of  the  muscles  of  the  back  of  the  neck,  occipital 
headache,  vertigo,  and  inco-ordination. 

Occipital  abscesses  often  give  rise  to  bilateral  homonomous 
hemianopsia.  The  skull  is  sometimes  sensitive  to  percussion 
over  the  affected  area. 


DISEASES  OF  THE  BRAIN  AND   ITS   MENINGES.     17 

Diagnosis. — A  correct  diagnosis  is  often  possible.  It  is 
usually  based  first  on  the  discovery  of  a  septic  focus  in 
some  part  of  the  skull,  especially  the  ear  and  the  frontal 
sinus,  or  in  some  other  part  of  the  body,  notably  the 
bronchi ;  secondly,  on  the  presence  of  fever,  rigors  followed 
by  sweating,  signs  of  a  rapidly  progressing  affection,  in- 
creasing intracranial  pressure  (optic  neuritis,  paralyses, 
sensory  or  optic  aphasia,  hemianopsia),  headache,  vertigo, 
convulsions,  percussion-tenderness  of  the  skull,  bruit  de  pot 
fele,  and  vomiting. 

Localization  is  often  beset  with  considerable  difficulty. 
"  The  greatest  certainty  in  the  diagnosis  of  otitic  abscesses 
is  reached  when  symptoms  are  present  which  can  be  assigned 
to  the  involvement  of  some  region  of  the  brain,  in  which  such 
abscesses  are  known  to  be  commonly  found  "  (Korner). 

In  regard  to  differential  diagnosis,  it  is  of  especial 
importance  to  be  able  to  distinguish  otitic  brain  abscesses 
from  otitic  extradural  abscesses  (pachymeningitis  externa 
purulenta),  sinus  thrombosis,  and  purulent  cerebrospinal 
meningitis.  The  clinical  picture  may  be  of  the  same  type 
in  all  these  affections. 

By  lumbar  puncture  information  may  be  obtained  as  to 
the  presence  of  meningitis.  If  the  affection  develops  from  one 
to  two  weeks  after  an  injury,  and  if  focal  symptoms  and  signs 
of  meningitis  are  present  together,  then  there  is  probably 
an  abscess  in  the  cortex.  When  there  is  torticollis,  tender- 
ness and  infiltration  along  the  jugular  vein,  and  other  signs 
of  thrombosis,  then  thrombosis  of  the  lateral  sinus  will  be 
diagnosed  ;  oedema  and  tenderness  over  the  mastoid  process 
will  confirm  this.  These  two  last  signs  are  also  evidence 
in  favour  of  the  presence  of  an  extradural  abscess.  A  point 
of  considerable  practical  importance  is  the  fact  that  a  simple 
suppurative  mastoiditis  may  be  the  cause  of  severe  cerebral 
symptoms,  probably  by  setting  up  a  serous  meningitis. 

In  distinguishing  abscess  from  tumour,  the  presence  of 
fever  is  important  ;  in  tumour  there  is  usually  no  rise  of 
temperature.  In  abscess,  also  focal  symptoms  appear  at  a 
relatively  late  period  ;  in  fact,  they  usually  mark  the 
beginning  of  the  end. 

In  children  with  tubercular  lesions,  glands,  etc.,  if  fever 
supervenes,  the  possibility  of  a  cerebral  or  meningeal  tuber- 
culosis should  be  considered. 


1 8  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS   FOR  OPERATION. 

Whenever  there  are  definite  dinical  signs  of  intracranial 
suppuration,  operation  is  called  for  without  delay,  whatever 
the  origin  of  the  abscess  may  be.  The  only  exceptions  will 
be  when  there  are  signs  of  diffuse  purulent  cerebrospinal 
meningitis,  and  when  the  general  condition  is  extremely  bad 
owing  to  some  other  intercurrent  affection.  An  exact 
topical  diagnosis,  although  of  course  of  great  advantage, 
should  not  be  considered  absolutely  necessary.  The  original 
seat  of  the  septic  affection  is  of  great  importance  as  a  guide 
to  the  probable  situation  of  the  abscess  and  the  operation. 
Otitic  abscesses  are  usually  found  in  the  temporal  lobe  of  the 
cerebellum  ;  abscesses  secondary  to  nasal  disease  in  the 
frontal  lobes. 

If  suppurative  ear  disease  is  present,  accompanied  by 
cerebral  symptoms,  which  do  not,  however,  with  certainty 
point  to  abscess  in  the  brain,  operation  should  be 
undertaken,  and  this  may  reveal  a  septic  focus  in  the 
mastoid,  or  an  extradural  abscess.  In  such  cases  the 
only  contra-indications  to  operation  will  be  the  presence 
of  severe  acute  sepsis,  involvement  of  the  ventricles, 
and  the  presence  of  diffuse  purulent  meningitis  as  revealed 
by  lumbar  puncture.  Operation  should  still  be  under- 
taken when  there  is  doubt  whether  one  has  to  deal  with 
a  purulent  meningitis  or  a  brain  abscess.  The  earlier  the 
operation  the  greater  the  chances  of  recovery.  Even  when 
an  exact  topographical  diagnosis  has  been  made  the  abscess 
may  not  be  discovered  at  the  operation,  or  a  second  abscess 
may  be  overlooked. 

Prognosis. — //  operation  be  undertaken. — Korner's  statis- 
tics, dealing  with  212  otitic  brain  abscesses,  show  recovery  in 
50  per  cent  ;  in  55  cerebellar  cases  there  were  52  per  cent 
successes.  In  many  cases  recovery  from  paralysis  and 
speech  defects  have  followed  operation. 

//  operation  he  not  undertaken. — The  patient  dies  in  a  short 
time  from  rupture  of  the  abscess  into  the  ventricles,  or 
diffusion  throughout  the  meninges  with  consequent  purulent 
meningitis.  Only  in  very  rare  instances  the  abscess  has 
discharged  externally  through  the  ear,  the  nose,  or  the 
temporal  bone,  and  recovery  has  followed.  Delay  in  these 
cases  is  therefore  fraught  with  grave  danger  to  the  life  of 
the  patient. 


DISEASES   OF   THE  BRAIN  AND   ITS   MENINGES.      19 

Consequences  of  operation  when  the  diagnosis  is  at  fault. — 
Operation  is  always  serious,  and  may  be  fatal,  but  the 
risks  of  operation  are  in  most  cases  not  so  great  that  they 
should  be  allowed  to  weigh  against  intervention  ;  the 
prognosis  of  abscess  is  too  absolutely  unfavourable  to  allow 
them  to  do  so.  Operation  may  give  rise  to  traumatic 
spreading  encephalitis,  serous  meningitis,  or  hernia  of  the 
brain. 

LITERATURE. 

Oppenheim. — Hirnabscess.  Nothnagel's  Handbuch  d.  spez. 
Pathol. 

Macewen.  Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal 
Cord.      1893. 

GowKRS. — Diseases  of  the  Nervous  System.     Vol.  ii. 

KoRNER. — Die  otitischen  Erkrankungen  des  Hirnes,  der  Hirnhaute. 
und  der  Blutleiter.     3rd  Ed.,  1902. 

Dreyfuss. — Die  Krankheiten  des  Gehirnes  u.  seiner  Adnexa  im 
Gefolge  V.  Naseneiterungen.      1896. 

Dreyfuss. — Rhinogene  Gehirnaffectionen.  Zentralb.  f.  d.  Grenz- 
gebiete  d.  ]Med.  u.  Chir.      1898,  p.  193. 

Henschen. — Hirnabscess.  Handbuch  d.  spez  Therap.  heraus- 
gegeben.     von  Pentzoldt-Stintzing.     3rd  Ed. 


SINUS  THROMBOSIS  AND  SINUS  PHLEBITIS. 

Etiology. — -Sinus  thrombosis  may  arise  from  several 
causes.  Thrombi  may  form  in  the  course  of  some  prolonged 
and  exhausting  affection  of  different  organs  ;  from  encroach- 
ment on  or  compression  of  the  sinus  by  a  new  growth  ; 
from  the  spread  to  the  sinus  of  some  inflammatory  process 
of  the  face  and  head  ;  from  otitis  media  and  caries  of  the 
temporal  bone  ;  from  some  general  change  in  the  condition 
of  the  blood.  Thrombosis  of  the  lateral  sinus  complicating 
middle-ear  and  mastoid  disease  will  chiefly  engage  our 
attention. 

Pathological  Anatomy. — The  thrombus  may  be  local, 
or  involve  the  greater  part  of  the  sinus,  the  latter 
especially  in  the  case  of  the  longitudinal  sinus.  The 
inflammatory  thrombi  are  found  in  the  neighbourhood 
of  the  primary  focus  ;  thus,  in  ear  affections  the  lateral 
sinus  is  attacked,  in  diseases  of  the  orbit  the  cavernous 
sinus.  The  thrombosis  is  set  up  either  by  spread  of 
the  inflammatory  process  to  the  wall  of  the  sinus,  by 
compression  of  the  latter,  or  by  direct  extension  through 


20  INDICATIONS    FOR    OPERATION    IN 

a  venule  from  the  seat  of  disease  (the  rare  osteo-phlebitis 
of  Korner)  ;  occasionally  it  is  due  to  the  erosion  of  the 
sinus  by  new  growth.  Thrombosis  of  the  lateral  sinus, 
by  far  the  most  frequent  of  all  forms,  often  extends  into  the 
internal  jugular  vein.  Usually,  when  secondary  to  ear 
disease,  septic  disorganization  of  the  clot  occurs,  and  by 
extension  of  the  process  to  surrounding  structures  local  or 
diffuse  purulent  meningitis,  an  extradural  abscess,  or  a  brain 
abscess  may  follow  ;  all  four  conditions  may  be  present  in 
any  given  case.  When  the  process  spreads  along  the 
internal  jugular  vein,  the  vein  wall  is  attacked  ;  abscesses 
then  develop  around  it  and  deep-seated  suppuration  in  the 
neck.  By  absorption  of  the  septic  material  and  disorgani- 
zation of  the  putrid  clot,  pulmonary  abscesses  and  pyaemia 
appear  in  the  later  stages. 

Clinical  Course. — Frequentlj/  thrombosis  is  discovered 
only  by  chance,  or  is  masked  by  other  symptoms.  The 
forms  which  are  of  chief  clinical  importance,  that  is  to  say, 
thrombosis  of  the  lateral  and  cavernous  sinuses,  are  usually 
characterized  by  high  fever,  intense  headache,  rigors,  a 
semi-conscious  condition,  increased  pulse  rate,  optic  neuritis 
(in  particular  unilateral),  frequent  vomiting,  profuse 
diarrhoea,  and  irregular  and  sudden  oscillations  of  tempera- 
ture, with  profuse  sweating.  After  several  days,  jaundice 
frequently  appears,  with  characteristic  coloration  of  the 
urine  ;  in  this  sometimes  only  urobilin  is  found.  In  the 
late  stages  swellings  of  the  joints,  gangrene  of  the  lung,  and 
other  septic  complications  are  common. 

In  addition  to  these  symptoms,  the  following  are  also 
often  observed  :  in  thrombosis  of  the  lateral  sinus,  oedema, 
swelling,  and  tenderness  over  the  mastoid  process,  pain  on 
skull  percussion,  and  unilateral  or  bilateral  optic  neuritis. 
The  attitude  of  the  head  (caput  obstipum)  is  characteristic, 
and  the  patient  complains  of  intense  pain  in  the  side  of  his 
neck.  Pressure  over  the  course  of  the  jugular  vein  is  painful, 
and  sometimes  the  thrombosed  vein  can  be  felt  as  a  long 
cord,  the  surrounding  parts  being  also  swollen.  Active 
rotation  of  the  head  is  usually  impossible,  and  passive 
rotation  is  painful  ;  nodding  is  usually  possible  and  painless, 
according  to  my  observation.  In  other  cases  there  is  rigidity 
of  the  neck,  tenderness  on  pressure  over  the  vertebrae,  and 
pain  in  swallowing.     Very  rarely  paralysis  of  the  palate  or 


DISEASES  OF   THE  BRAIN  AND   ITS   MENINGES.     21 

vocal  cords  is  found  ;  it  has  not  been  present  in  any  of  the 
numerous  cases  I  have  seen.  Unequal  distension  of  the 
jugular  vein  is  very  uncommon. 

Thrombosis  of  the  cavernous  sinus  is  usually  accompanied 
by  protrusion  of  the  eyeball,  oedema  of  the  lids,  or  chemosis. 
The  cerebral  and  palpebral  veins  are  distended,  and  the 
forehead  is  cyanotic.  Patients  often  complain,  in  the  early 
stages,  of  pain  along  the  frontal  branch  of  the  fifth  cranial 
nerve  ;  diplopia  is  also  present,  owing  to  involvement  of  the 
nerves  supplying  the  eye  muscles,  and  sometimes  immobility 
of  the  eye  develops  rapidly  from  paralysis  of  the  oculo- 
motor, abducens,  and  trochlear  nerves.  Optic  neuritis  is 
frequent. 

Diagnosis — When  there  is  present  one  of  the  head 
affections  which  are  commonly  complicated  by  sinu3 
thrombosis,  such  as  chronic  middle-ear  disease,  and  the 
patient  exhibits  the  symptoms  described  above,  the  diag- 
nosis may  be  made  ;  it  is  often  impossible,  however,  to  be 
sure  how  far  the  meninges  on  the  one  hand,  and  the  brain 
on  the  other,  are  involved.  Meningeal  symptoms  may  be 
simply  due  to  irritation.  In  my  experience  much  importance 
is  to  be  attached  to  oedema  over  the  mastoid  process,  the 
typical  attitude  of  the  head,  tenderness  over  the  jugular 
vein,  and  signs  of  thrombosis  in  it,  when  these  are  associated 
with  phenomena  of  pyaemia.  Sinus  thrombosis  is  always 
very  probable  when  pyaemic  symptoms  supervene  on  an 
otitis  (Lenhart).  Brieger  has,  however,  drawn  attention  to 
the  fact  that  phlebitis  of  the  diploic  veins  may  be  the 
starting-point  of  otitic  pyaemia  without  infection  of  the 
sinus  ;   such  cases  are,  however,  exceptional. 

Differential  diagnosis. — As  above  stated,  it  is  im- 
possible in  many  cases  to  arrive  at  a  certain  diagnosis 
between  sinus  thrombosis  and  brain  abscess,  extradural 
abscess,  or  diffuse  meningitis,  especially  since  the  former  is 
often  complicated  by  one  of  these.  A  rapid  and  irregular 
pulse,  a  high  temperature  with  rapid  remissions,  profuse 
sweating  and  diarrhoea,  frequent  rigors  and  pyaemic  symp- 
toms, point  to  sinus  thrombosis.  The  intellectual  faculties 
often  remain  unclouded  to  the  last  stages.  The  early  appear- 
ance of  a  transitory  motor  aphasia,  the  presence  of  pus  and 
the  formation  of  a  coagulum  in  the  fluid  obtained  by 
lumbar  puncture,  are  in  favour  of  a  diagnosis  of  meningitis. 


22  INDICATIONS    FOR    OPERATION    IN 

Hemianopsia  and  optic  aphasia  point  to  cerebral  abscess. 
In  abscess  the  temperature  is  usually  only  moderately  high, 
the  pulse  is  slow,  and  the  intellectual  faculties  dull. 

It  should  be  remembered  that  tenderness  on  pressure 
along  the  course  of  the  jugular  may  be  due  to  other 
inflammatory  lesions,  such  as  lymphadenitis  and  abscesses 
secondary  to  cervical  caries.  A  lymphangitis  may  also  give 
rise  to  the  formation  of  a  tender  cord-like  swelling  in  the 
neighbourhood  of  the  jugular  vein,  and  may  complicate 
mastoid  disease  without  the  sinus  being  involved. 

INDICATIONS   FOR  OPERATION. 

Sinus  phlebitis  has  often  been  operated  on  with  success*, 
frequently  when  pysemic  symptoms  have  commenced,  and 
thrombosis  of  the  jugular  is  established.  Operative  inter- 
ference is  therefore  indicated  in  all  cases  of  uncomplicated 
sinus  thrombosis  (see  paragraph  above)  unless  severe  com- 
plications are  already  present  in  other  organs  and  the 
patient's  vitality  is  greatly  depressed.  Although  it  is 
impossible  to  be  certain  before  operation  whether  the  lesion 
is  confined  to  the  sinus,  yet  this  must  not  be  allowed  to  weigh 
against  operation  if  the  two  contra-indications  just  mentioned 
are  absent.  Operation  is  equally  indicated  if  it  is  thought 
probable  that  the  sinus  phlebitis  is  complicated  by  cerebral 
abscess,  or  extradural  abscess,  or  circumscribed  meningitis. 
The  earlier  the  operation,  the  better  the  chances  of  success. 
Commencing  jugular  thrombosis  is  no  contra-indication. 

Sinus  phlebitis  is  so  often  undiagnosed  that  it  is  advisable 
in  all  cases  of  extensive  operation  for  acute  purulent  ear- 
disease  to  open  the  lateral  sinus  on  diagnostic  and  thera- 
peutic grounds. 

Contra-indications  to  operation  are  severe  pyaemia, 
multiple  metastatic  foci  in  distant  organs  (e.g.,  the  lungs) ;^, 
gangrene  of  the  lung  following  septic  and  gangrenous  infarct, 
endocarditis,  nephritis,  pyaemic  arthritis,  jaundice. 

If  lumbar  puncture  reveals  the  presence  of  purulent 
cerebrospinal  meningitis,  no  operation  should  be  undertaken 


*  In  305  cases  of  operation  collected  by  Korner,   180  recovered  and 
125   died. 

§  A  solitary   pulmonary  abscess   is  no  absolute  bar   to  operation,  but 
can  rarely  be  diagnosed  clinically. 


DISEASES  OF  THE  BRAIN  AND   ITS  MENINGES.     23 

(recently  some  authors  have  urged  operation  in  these 
desperate  cases  on  the  ground  of  an  occasional  success). 
If  there  is  reason  to  believe  that  there  is  phlebitis  of  the 
cavernous  as  well  as  the  lateral  sinus,  operation  is  almost 
always  contra-indicated  on  account  of  the  extent  of  the 
lesion. 

Tuberculosis  of  the  mastoid  process  or  the  temporal  bone, 
with  consecutive  sinus  thrombosis,  does  not  contra-indicate 
operation,  unless  the  general  condition  of  the  patient  is  very 
bad,  or  advanced  tuberculosis  is  discovered  in  other  organs. 
No  operation  should  be  done  in  carcinoma  of  the  temporal 
bone. 

Prognosis. — Of  operation. — The  figures  which  have  been 
quoted  above  show  that  the  prognosis  is  relatively  good  ; 
the  more  favourable  the  earlier  the  operation.  Two  out 
of  five  operated  on  died. 

When  no  operation  is  undertaken,  the  results  of  sinus 
phlebitis  are  in  general  very  bad.  In  most  cases  the  disease 
is  rapidly  fatal.  Exceptionally,  however,  a  case  of  advanced 
sinus  phlebitis  has  recovered  without  operation. 

Risks  of  operation  when  the  diagnosis  is  faulty. — The  danger 
attached  to  opening  the  sinus  is  comparatively  small.  Fatal 
air  aspiration  has  been  recorded  once  (Kuhn)  ;  infection 
through  the  wound  of  the  sinus  is  rare. 

The  trauma  entailed  by  the  operation  of  opening  the 
skull  may  set  up  a  traumatic  encephalitis,  but  this  is  very 
exceptional. 

LITERATURE. 

O.  KoRNER.  Die  otitischen  Erkrankungen  des  Hirnhaute  und 
der  Blutleiter,   3rd  Ed.,  1902. 

Oppenheim.    Hirnabscess.    Nothnagel's  Handbuch  d.  spez.  Pathol. 

Macewen.  Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal 
Cord.      1893. 

Bergmann.  Die  Chirurgische  Behandlung  der  Hirnkrankheiten, 
3rd  Ed.,  1899. 

Zaufal.  Sinusphlebitis.  Prag.  Med.  Wochens.  1884,  p.  474, 
und  1896,  No.  49. 

Hammerschlag.     Monats.  f.  Ohrenheilk,  1900,  p.  127. 

HYDROCEPHALUS. 

Etiology. — The  general  etiology  of  hydrocephalus  need 
not  be  discussed  here,  for  only  a  few  of  the  forms  of  the 
condition  are  suitable  for  surgical  treatment  ;   acute  hydro- 


24  INDICATIONS    FOR    OPERATION    IN 

cephalus,  due  to  serous  or  tubercular  meningitis,  or  to 
cerebral  tumour,  is  not,  in  my  opinion,  included  among 
these.  Operation  is  called  for  in  the  chronic  congenital 
type,  but  not  in  the  chronic  acquired  form,  such  as  that 
following  closure  of  the  foramen  of  Magendie  or  the  foramen 
of  Monro,  or  that  due  to  tumour,  for  the  reason  that  a 
differential  diagnosis  between  the  latter  and  cerebral  tumour 
is  hardly  possible,  and  consequently  the  chances  of  successful 
surgical  treatment  are  of  the  smallest.  In  such  cases  the 
most  that  can  be  done  is  a  palliative  operation  for  the  relief 
of  intracranial  pressure,  prolonging  a  miserable  existence  for 
a  short  period. 

Pathological  Anatomy. — Bergmann's  definition  gives  in 
a  few  words  the  essential  points.  He  says  :  "  Chronic 
hydrocephalus  is  characterized  by  a  progressive  increase  of 
the  fluid  in  the  ventricles  of  the  brain,  and  by  a  correspond- 
ing distension  of  the  skull  of  the  child,  whose  sutures  and 
fontanelles  are  still  unclosed."  The  amount  of  fluid  in  the 
ventricles  is  sometimes  enormous,  the  cortex  and  the  rest  of 
the  brain  being  extremely  thin  and  diffusely  atrophic,  the 
floor  of  the  third  ventricle  forming  a  cystic  swelling.  The 
sutures  gape  and  the  fontanelles  are  greatly  enlarged,  the 
forehead  bulging  forwards.  The  structures  at  the  base  of 
the  brain  appear  compressed.  The  fluid  in  the  ventricles  is 
similar  in  composition  to  the  cerebrospinal  fluid.  The 
circumference  of  the  head  is  much  greater  than  normal, 
and  the  bones  of  the  skull  are  not  unusually  thin  and 
transparent. 

Clinical  Course  and  Diagnosis. — In  addition  to  the 
signs  already  mentioned,  a  few  others  only  require  to  be 
noted  in  regard  to  the  question  of  diagnosis.  The  face 
appears  small,  the  position  of  the  eyeballs  is  modified  by  the 
narrowing  of  the  orbits,  and  the  hair  is  scanty  ;  often 
nystagmus  and  tremors  of  the  face  are  to  be  noted,  and 
optic  neuritis  or  a  simple  optic  atrophy.  The  intellectual 
faculties  are  often  feeble,  and  definite  dementia  is  not 
uncommon. 

Often  the  head  cannot  be  held  upright  ;  sometimes  motor 
paresis  of  the  upper  and  lower  extremities  is  present,  often 
associated  with  spastic  phenomena  or  tremors.  The  tendon 
reflexes  are  much  exaggerated,  and  in  advanced  stages 
general  convulsions  occur. 


DISEASES   OF   THE  BRAIN  AND   ITS   MENINGES.     25 

Differential  diagnosis. — The  differential  diagnosis  from 
rachitic  changes  in  the  skuh  is  of  special  importance,  these 
being  only  part  of  general  bone  changes  throughout  the 
skeleton.  In  rickets  the  skull  is  square,  and  craniotabes  is 
not  uncommon.  A  very  pronounced  increase  in  the  size  of 
the  skull  negatives  simple  rachitis,  while  favourable  results 
from  the  administration  of  phosphorus  are  evidence  in  its 
favour. 

It  is  also  important  to  distinguish  the  congenital  from  the 
acquired  form  of  hydrocephalus.  The  most  important  point 
is  the  fact  that  in  the  latter  the  enlargement  of  the  head 
does  not  date  from  the  first  few  months  of  the  child's  life. 
If  the  evidence  on  this  point  is  not  clear,  assistance  may  be 
obtained  from  a  history  of  meningeal  symptoms  having 
preceded  the  enlargement  of  the  head  ;  if  this  is  the  case  it 
will  point  to  the  acquired  form. 

INDICATIONS   FOR  OPERATION. 

Operation  does  not  necessarily  follow  on  a  diagnosis  of 
congenital  hydrocephalus  ;  the  condition  may  spontaneously 
come  to  a  standstill.  When  the  increase  of  the  head  is  rapid 
and  continuous,  and  the  signs  of  intracranial  hypertension 
become  prominent  (slowing  of  the  pulse,  Cheyne-Stokes 
respiration,  vomiting,  and  intellectual  dullness),  and  if 
general  convulsions  make  their  appearance,  then  the  question 
of  operation  must  be  considered.  Generally  speaking,  opera- 
tion is  justifiable  when  the  condition  endangers  life  :  such 
an  operation  may  be  either  lumbar  puncture  or  drainage  of 
the  ventricles. 

Another  indication  for  operation  arises  when  optic  neuritis 
or  commencing  atrophy  threatens  total  blindness  ;  and, 
thirdly,  when  there  is  intense  and  persistent  headache. 

Operation  has  been  undertaken  of  late  years  in  the  hope 
of  improving  the  bodily  and  mental  functions  which  suffer 
so  severely  in  the  course  of  the  disease,  and  with  a  view  to 
improving  the  hydrocephalic  dementia,  using  the  latter 
term  in  its  widest  sense. 

Contra-indications. — Operation  should  not  be  undertaken 
if  prolonged  antisyphilitic  treatment  or  the  administration 
of  phosphorus  has  brought  about  an  arrest  in  the  progress 
of  the  condition,  or  a  disappearance  of  the  symptoms  of 
raised   intracranial   pressure.      Operation   must   be   looked 


26  INDICATIONS    FOR    OPERATION    IN 

upon  as  by  no  means  free  from  risk.  It  will  not  be  recom- 
mended when  the  general  condition  is  very  low,  when  there 
is  marked  dementia,  when  optic  atrophy  is  complete,  or 
when  the  child  is  suffering  from  some  other  severe  compli- 
cating affection.  Even  when  operation  is  well  borne,  the 
good  local  results  are  liable  to  be  outweighed  by  persistent 
intellectual  defect,  idiocy,  and  imbecility.  Chronic  stationary 
hydrocephalus  should  not  be  operated  on  when  the  skull  is 
completely  ossified  ;  no  improvement  would  follow  under 
such  circumstances. 

Prognosis. — After  operation. — This  will  vary  according 
to  the  mode  of  intervention.  Spinal  puncture,  if  done  with 
the  necessary  precautions,  is  not  particularly  dangerous,  but 
what  improvement  it  causes  is  only  temporary,  and  it  has  to 
be  frequently  repeated  to  obtain  a  permanent  result.  It 
can  only  be  successfully  done  when  the  aqueduct  of  Sylvius, 
the  foramen  of  Magendie,  and  the  other  channels  are  patent. 
The  operations  by  which  fluid  is  evacuated  directly  from 
the  dilated  ventricles  are  all  attended  with  risk,  and  only  a 
few  cases  have  been  benefited  or  cured  thereby.  In  sixty- 
five  cases  collected  by  Henschen  there  were  twenty-four 
fatalities  ;  in  twelve  there  was  no  improvement,  sixteen  were 
cured,  and  thirteen  improved.  Probably  many  unfavourable 
cases  are  not  reported,  and  there  is  reason  to  believe  that 
the  mortality  is  higher  than  these  figures  represent. 
Drainage  of  the  ventricles  gives  the  worst  results  of  all ;  of 
twenty-three  cases  thus  treated,  sixteen  died. 

The  operations  which  have  been  hitherto  devised  for  hydro- 
cephalus {especially  ventricular  drainage)  must  therefore  he 
considered  of  very  doubtful  utility  ;  but  at  the  same  time  it 
cannot  be  denied  that  definite  cure  may  he  obtained  by  these 
means. 

Consequences  of  operation. — Operation  may  be  followed  by 
fatal  septic  infection  (meningitis,  abscess).  Spinal  puncture 
alone  may  occasion  serious  and  even  lethal  syncope,  owing 
to  a  too  rapid  and  abundant  escape  of  fluid  ;  it  is  well  to 
repeat,  therefore,  that  it  is  attended  with  definite  risks. 
When  a  palliative  operation  is  undertaken,  with  the  idea  of 
rescuing  the  patient  from  complete  blindness,  the  least 
dangerous,  that  is  to  say  spinal  puncture,  should  be 
chosen. 

Prognosis    without   operation. — The    hydrocephalus    itself 


DISEASES  OF   THE  BRAIN  AND   ITS   MENINGES.     27 

may  become  stationary,  while  marked  motor  and  intellectual 
symptoms  persist  (an  unusual  event),  and  the  damage  to  the 
sensory  nerves,  especially  the  optic  nerves,  progresses.  On 
the  other  hand  the  hydrocephalus  may  increase  and  produce 
symptoms  of  progressive  intracranial  tension,  with  or 
without  intercurrent  complications,  bringing  about  a  fatal 
result  in  the  course  of  time.  This  may  be  a  few  months  or 
several  years. 

Spontaneous  recovery  may  take  place,  but  the  chances  of 
its  occurrence  are  small  in  any  given  case.  Sometimes  the 
fluid  finds  an  exit  by  the  nose,  throat,  or  orbit  ;  then  recovery 
may  follow  if  no  secondary  infection  intervenes.  About  a 
dozen  cases  of  spontaneous  rupture  are  recorded  in  the 
literature. 

LITERATURE. 

Bergmann.  Die  Chirurgische  Behandlung  der  Hirnkrankheiten. 
3rd  Ed.     Berlin,   1899. 

D'AsTROS.     Les  Hydrocephalies.     Pads,   1898.     G.  Steinheil. 

Neurath.  Lumbalpunktion.  Zentralb.  f.  d.  Grenzgebiete  d. 
Med.  u.  Chir.      1898. 

A.  Starr.     Cerebral  Surgery. 

Henle.  Wasserkopf.  Mitteilung.  aus  den  Grenzgebieten. 
Bd.   I. 

HEN5CHEN.  Handbuch  der  spez.  Therap.  von  Penzoldt-Stintzing. 
3rd  Ed. 

EPILEPSY. 

Definition,  Etiology,  and  Pathological  Anatomy. — 
By  the  term  epilepsy  is  understood  a  condition  characterized 
by  frequently  recurring  attacks  of  sudden  loss  of  conscious- 
ness, with  general  convulsions,  at  first  of  tonic,  and  later  of 
clonic,  type.  In  habitual  epilepsy  generally  speaking,  an 
idiopathic,  a  symptomatic,  and  a  reflex  type  are  to  be 
distinguished,  although  this  distinction  is  not  always 
possible. 

To  the  symptomatic  type  belong  those  cases  in  which 
gross  anatomical  cerebral  lesions  (hydrocephalus,  tumour, 
abscess,  extensive  softening)  or  diseases  of  other  organs, 
such  as  the  kidneys,  are  associated  with  epileptic  attacks 
in  addition  to  other  symptoms.  Reflex  epilepsy  is  that 
form  in  which  convulsions  of  epileptic  type  are  set  up  by 
some  discoverable  irritation  of  the  peripheral  nervous 
system  ;  in  such  cases,  it  must  be   noted,  that  a  state  of 


28  INDICATIONS    FOR    OPERATION    IN 

pathological  excitability  of  the  central  nervous  system  is 
also  present. 

In  idiopathic  epilepsy  no  constant  and  characteristic 
anatomical  changes  have  yet  been  found,  but  among  other 
lesions  the  following  have  been  most  frequently  observed  : 
old  cicatrices,  circumscribed  cysts,  local  sclerosis,  haemor- 
rhages (traumatic),  bone  splinters,  and  hyperostoses.  There 
are  many  cases  in  which  no  anatomical  anomalies  are 
found. 

The  most  important  etiological  factors  in  epilepsy  are 
the  intoxications  (alcohol,  lead),  the  infective  diseases 
(syphilis,  malaria),  heredity,  psychic  influences,  and  head 
injuries. 

Clinical  Course. — Epileptic  seizures  are  of  several 
different  types  :  (i)  The  "  petit  mal  "  ;  minor  attacks 
without  or  with  only  slight  convulsive  movements,  but  with 
loss  of  consciousness.  (2)  The  major  attacks,  with  pro- 
dromal symptoms  of  the  nature  of  an  "  aura,"  with  loss  of 
consciousness,  first  tonic  and  then  clonic  convulsions  of  the 
whole  muscular  system,  initial  cry,  and  biting  of  the  tongue, 
followed  by  stupor  and  drowsiness,  and  sometimes  by 
psychic  disturbances.  (3)  The  partial  seizures  (cortical 
epilepsy,  Jacksonian  epilepsy),  in  which,  after  a  prodromal 
"  aura,"  the  convulsions  either  chiefly  or  exclusively  affect 
one  side  of  the  body  and  then  pass  off,  usually  in  the  order 
in  which  they  appeared. 

If  the  convulsions,  first  tonic,  then  clonic,  are  confined  to 
one  side,  consciousness  is  usually  unaffected  ;  if  they  spread 
to  the  opposite  side  it  is  usually  lost.  The  attacks  of  the 
second  and  third  types  often  appear  in  series.  When  the 
attacks  succeed  each  other  with  great  rapidity,  a  status 
epilepticus  is  established. 

Diagnosis  and  Differential  Diagnosis. — When  the 
attacks  are  well  marked  the  diagnosis  is  readily  made.  They 
will  be  distinguished  from  hysteria  by  the  biting  of  the 
tongue,  the  serious  injuries  which  the  patient  sometimes 
suffers  in  an  attack,  and  by  the  complete  loss  of  conscious- 
ness. Incontinence  of  urine  and  faeces  during  an  attack, 
and  the  occurrence  of  the  latter  during  sleep,  point  to  true 
epilepsy.  Hysterical  phenomena  and  hysterical  convulsions 
will  enable  one  to  distinguish  hysteria  from  an  apparent 
"  petit  mal."     Symptomatic  epilepsy  may  be  distinguished 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES.     29 

from  idiopathic  epilepsy  by  the  presence  of  anomalous 
phenomena  not  characteristic  of  the  latter,  at  any  rate  after 
one  has  had  the  patient  under  observation  for  some  time. 

INDICATIONS   FOR   OPERATION. 

These  have  been  very  differently  stated  at  different 
periods.     At  the  present  time  the  following  may  be  given  : — 

Reflex  epilepsy. — Operation  is  called  for  when  the  diagnosis 
of  a  reflex  epilepsy  is  clear  ;  that  is  to  say  when  the  attacks 
are  dependent  on  some  peripheral  lesion  (a  tumour,  a  painful 
ricatrix),  as  shown  by  the  fact  that  the  aura  makes  its 
appearance  in  the  latter,  with  twitching  of  the  neighbouring 
muscles,  and  spreads  thence  to  the  rest  of  the  body,  and 
when  the  attacks  can  be  set  up  by  pressure  at  the  seat  of 
the  lesion.  Such  operation  will  consist  in  the  removal  of 
the  disease  focus  (tumour,  scar,  hyperostosis). 

Symptomatic  epilepsy. — The  indications  for  operation  will 
here  be  guided  by  those  relative  to  the  tumour,  abscess,  or 
other  condition  to  which  the  epileptic  attacks  are  due.  In 
this  type,  as  also  in  Idiopathic  epilepsy,  the  skull  should  be 
opened  when  there  is  a  history  of  a  trauma  shortly  preceding 
the  onset  of  the  convulsions.  Operation  is  absolutely 
indicated  in  recent  cases  in  which  there  is  a  palpable  lesion, 
such  as  a  depression  of  the  bones  of  the  skull,  or  in  which 
there  are  one-sided  convulsions  associated  with  other  marked 
cerebral  symptoms.  It  is  also  indicated  in  cases  of  somewhat 
longer  standing,  in  which  there  is  definite  cortical  epilepsy 
constantly  commencing  at  a  definite  spot  on  one  side  of  the 
body,  and  when  there  is  an  "  aura  "  referred  to  that  part 
in  which  the  muscular  twitchings  first  occur.  In  all  such 
cases,  however,  operation  will  only  be  undertaken  when 
a  course  of  treatment  with  bromides  has  been  tried  and 
found  ineffectual. 

Centra-indications  to  operation. — In  reflex  epilepsy,  the 
generalization  of  the  convulsions  over  the  whole  muscular 
system  in  each  attack  negatives  the  idea  of  operation.  When 
this  is  the  case  it  indicates  the  existence  of  such  pronounced 
changes  in  the  central  nervous  system  as  to  make  it  probable 
that  even  after  removal  of  the  original  irritative  cause  the 
convulsions  will  continue. 

In  idiopathic  epilepsy,  operation  is  contra-indicated  vv'hen 
there  are  no  local  symptoms  enabling  one  to  diagnose  the 


30  INDICATIONS    FOR    OPERATION    IN 

site  of  a  local  brain  lesion,  when  convulsions  are  not  one- 
sided, when  no  bone  depression  or  exostosis  is  manifest  in  a 
case  presenting  the  history  of  a  trauma,  and  so  on. 

Simple  trephining  of  the  skull  at  some  point  or  other, 
which  was  at  one  time  frequently  practised,  often  produces 
a  transitory  improvement,  but  no  permanent  good  result. 
For  resection  of  the  sympathetic,  which  has  been  done  in 
many  cases  more  recently,  no  favourable  curative  results  can 
be  claimed. 

In  cortical  epilepsy,  when  operation  reveals  no  apparent 
abnormality  of  the  cortex,  no  resection  of  the  latter  should 
be  done,  although  Horsley  recommended  it. 

In  all  cases  where  there  is  no  history  of  acute  onset 
(trauma),  no  operation  should  be  undertaken  for  the  con- 
vulsions until  energetic  treatment  with  bromides  has  been 
tried  and  failed.  If  there  is  a  definite  or  even  only  a 
probable  history  of  syphilis,  an  antisyphilitic  course  of 
treatment  should  be  prescribed  before  recommending 
operation. 

Prognosis. — Risks  of  operation. — In  reflex  epilepsy  these 
are  usually  slight.  They  are  more  serious  when  the  skull  is 
opened,  for  this  operation  is  itself  always  a  severe  one. 
Sensory  and  motor  defects  may  persist  for  a  long  time  after 
the  removal  of  apparently  normal  portions  of  the  cortex  in 
hemi-epilepsy.  I  have  seen  such  still  existent  years  after 
operation.  In  every  case  of  trephining  there  is  a  risk  that 
the  resulting  scar  may  itself  prove  the  cause  of  epileptic 
seizures. 

Results  without  operation. — In  reflex  epilepsy  the  establish- 
ment of  general  epileptic  attacks  is  to  be  expected  ;  this  is 
true  also  for  traumatic  and  non-traumatic  cortical  epilepsy. 

LITERATURE. 

BiNSWANGER.  Die  Epilepsie.  Xothnagel's  Handbuch  der 
spez.  Pathol.     Wien.      1899. 

Jolly.  Handbuch  der  praktischen  ^ledizin  (Ebstein-Schwalbe), 
1900. 

Bergmann.  Die  Chirurgische  Behandlung  der  Hirnkrankheiten. 
3rd.  Ed.,  Berlin,  1898. 

PiLCZ.  Die  Chirurgische  Behandlung  der  Epilepsie.  Centralb.  f. 
d.  Grenzgebiete  d.  Med.  u.  Chir.      1901. 

GowERS.     Epilepsy. 

Henschen.  Epilepsie.  Handbuch  der  spez.  Pathol.  von 
Penzoldt-Stintzino;.     2nd  Ed. 


DISEASES   OF   THE  BRAIN  AND   ITS   MENINGES.      31 

THE  CEREBRAL  PALSY  OF  CHILDREN. 

Etiology. — This  condition  may  be  either  congenital  or 
acquired.  The  acquired  form  is  caused  by  injuries  at  birth, 
injuries  of  other  kinds,  the  infectious  diseases,  embolus,  and 
thrombosis  of  the  cerebral  vessels,  the  latter  associated 
specially  with  syphilis. 

Pathological  Anatomy. — No  constant  anatomical 
changes  have  been  found  ;  usually  some  process  which  is 
no  longer  active,  the  chief  being  foci  of  softening,  cysts, 
indurations,  and  porencephaly.  Sometimes  a  fine  plication 
of  the  grey  matter  of  the  cortex  has  been  found,  the  so- 
called  microgyria.  Thickening  of  the  meninges  and  cysts 
of  the  meninges  are  common.  Often  the  whole  hemisphere 
is  shrunken  and  sclerotic.  The  motor  region  is  that  most 
commonly  and  most  severely  affected. 

Clinical  Phenomena. — Hemiplegia  is  the  characteristic 
phenomenon.  The  paralysis  does  not,  however,  remain 
complete,  but  recedes  to  a  certain  extent.  It  affects,  as  in 
the  adult,  the  extremities  and  the  face  on  one  side,  and 
there  is  often  also  paresis  of  the  hypoglossal  on  the  same 
side.  The  paralysis  is  of  the  spastic  type,  and  contracture 
is  in  many  cases  a  more  prominent  symptom  than  the 
paralysis.  The  reflexes  are  exaggerated  on  the  paralysed 
side,  and  Babinski's  sign  is  often  present.  Hemiathetosis 
and  hemichorea  are  exceptionally  frequent.  Usually  there 
are  no  sensory  abnormalities.  The  paralysed  extremities 
often  show  arrest  in  growth  and  muscular  development. 
Epilepsy  and  idiocy  are  common,  but  the  idiocy  is  not 
complete,  and  may  only  consist  of  slight  w^eakness  of  intellect, 
or  some  anomalous  characteristics.  In  many  cases  the 
condition  is  bilateral  (cerebral  diplegia). 

Diagnosis. — The  symptoms  will  render  the  diagnosis 
clear  ;  the  spastic  and  non-degenerative  character  of  the 
hemiplegia,  the  intellectual  weakness,  the  epilepsy,  hemi- 
chorea, hemiathetosis,  etc.  As  a  rule  it  is  easy  to  avoid 
confounding  the  condition  with  birth  palsy  (the  flaccid 
paralysis  of  an  arm),  or  poliomyelitis  (degenerative  paralysis). 

INDICATIONS   FOR   OPERATION. 

Trephining,  with  removal  of  the  morbid  focus,  is  indicated 
if  epilepsy,  chorea,  and  athetosis  are  present,  unless  some 


32  INDICATIONS    FOR    OPERATION    IN 

particular  contra-indication  is  present,  such  as  general 
feebleness,  heart  failure,  tuberculosis  (Henschen).  The 
hemiplegia  will  not  be  improved  by  operation,  and  therefore 
in  itself  is  not  an  indication  for  intervention.  Plastic  opera- 
tions on  the  muscles  and  tendons  are  indicated  for  the 
disabilities  produced  by  contracture  and  paresis. 

Contra-indicaiions. — In  addition  to  those  already  men- 
tioned the  presence  of  diplegia  is  against  operation,  nor 
should  this  be  advised  when  epileptic  seizures  are  only 
occasional,  because,  although  they  are  sometimes  improved 
thereby,  it  is  b}^  no  means  certain  that  this  will  follow  in 
any  given  case. 

Prognosis. — Dangers  and  results  of  operation. — Hitherto 
the  results  of  trephining  have  not  been  particularly  encourag- 
ing, for  in  some  of  the  cases  death  has  followed  and  been 
directly  assignable  to  it.  It  must  therefore  be  looked  upon 
as  distinctly  dangerous.  In  another  group  of  cases  the  im- 
provement that  has  followed  has  been  only  transient.  The 
attacks  of  muscular  spasm  or  the  epileptic  seizures  improve 
or  disappear,  only  to  return  after  the  lapse  of  a  longer  or 
shorter  period.  Usually  they  appear  after  a  few  months, 
and  sometimes  worse  than  ever.  Complete  recovery  is 
exceptional.  Only  therefore  in  cases  where  the  symptoms 
(epilepsy,  choreiform  spasm)  are  extreme  and  intolerable, 
will  operation  be  recommended  :  that  is  to  say,  trephining, 
with  removal  of  the  morbid  focus. 

The  results  of  tendon  transplantation  are  more  encourag- 
ing. The  function  of  useless  limbs  can  be,  in  part  at  any 
rate,  restored,  and  the  risks  of  operation  are  minimal. 

Results  without  operation. — When  contracture,  athetosis, 
or  chorea  develop,  the  limb  will  be  rendered  almost  com- 
pletely useless.  The  onset  of  epileptic  fits  leads  up  to 
chronic  epilepsy  and  the  danger  of  the  status  epilepticus. 
Generally  speaking,  however,  the  life  of  the  patient  is  not 
endangered  by  his  affection. 

LITERATURE. 

Freud.  Kinderlahmung.  Nothnagel's  Handbuch  d.  spez  Pathol, 
u.  Therap.     Bd.  ix.     Wien. 

Sachs.  Hirnlahmungen  der  Kinder.  Volkmann's  Sammlung 
klin.  Vortrasje.     Neue  Folge,  46  and  47. 

Henschen.  Cerebrale  Kinderlahmung.  Handbuch  der  spez. 
Therap.     von  Penzoldt-Stintzing.     Bd.  vi 


DISEASES  OF  THE  BRAIN  AND   ITS  MENINGES.     33 

CEREBRAL    HAEMORRHAGE. 

The  cerebral  haemorrhage  which  follows  injury  will  alone 
be  discussed  here  ;  the  spontaneous  haemorrhages  of  the 
brain  have  so  rarely  been  submitted  to  operation,  that 
no  discussion  of  indications  and  contra-indications  is 
possible. 

Etiology. — ^Traumatic  cerebral  haemorrhage  may  be 
occasioned  by  a  comparatively  slight  as  well  as  by  a  severe 
injury. 

Pathological  Anatomy. — There  may  or  may  not  be  a 
severe  skull  lesion  associated  with  the  intracranial  haemor- 
rhage. Extradural  haemorrhage  is  usually  due  to  tearing  of 
the  middle  meningeal  artery  ;  intradural  haemorrhage 
usually  comes  from  a  pial  vein.  The  clot  may  be  very 
large  and  exert  severe  pressure  on  the  brain.  Multiple 
lesions  of  brain,  meninges,  and  skull  are  often  caused  by  the 
one  injury. 

Clinical  Course. — It  may  be  very  difficult  to  decide 
whether  haemorrhage  is  intra-  or  extradural ;  in  many  of 
my  cases  of  intradural  haemorrhage,  the  fluid  drawn  off  by 
lumbar  puncture  has  contained  blood.  As  a  rule  there  is  an 
interval,  which  may  be  an  hour  or  may  be  as  long  as  ten  days, 
between  the  injury  and  the  onset  of  pressure  symptoms  ; 
the  patient  then  becomes  increasingly  drowsy,  his  pulse 
slows,  and  vomiting  and  convulsions  commence.  The 
convulsions  may  be  of  the  type  of  cortical  epilepsy, 
and  may  be  strictly  localized,  e.g.,  to  the  face  muscles. 
Hemiplegia  then  appears  and  becomes  more  and  more 
pronounced,  affecting  the  side  of  the  body  (including 
the  face)  opposite  to  that  of  the  injury  ;  hemihyperaesthesia 
may  be  associated  with  this.  In  left-sided  lesions  aphasia 
may  sometimes  be  made  out.  As  the  haemorrhage  and 
the  pressure  increase,  paresis  develops  on  the  same  side 
as  the  lesion,  the  respiratory  rhythm  becomes  of  the 
Cheyne-Stokes  type,  the  pupils  become  dilated,  and  the 
patient  passes  into  a  condition  of  coma,  terminating  in 
death. 

Diagnosis. — The  diagnosis  is  based  on  the  appearance 
after  injury  of  the  symptoms  enumerated  ;  paralysis  of  the 
opposite  side,  cortical  epileptic  attacks,  and  the  gradual 
increase  of  the  signs  of  cerebral  compression. 

3 


34  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS   FOR  OPERATION. 

The  skull  must  always  be  opened  when,  after  injury  to  the 
head,  signs  of  progressive  cerebral  compression  are  associated 
with  the  presence  of  a  definite  lesion  of  the  cranial  vault. 
If  no  such  lesion  can  be  found,  operation  should  still  be  under- 
taken when  the  signs  of  compression  steadily  advance,  and 
when  these  signs  are  such  that  the  site  of  the  haemorrhage  can 
be  diagnosed.  If,  however,  the  compression  symptoms  are 
stationary,  and  not  of  a  severe  type,  the  advice  given  by 
Allen  Starr  is  to  wait,  for  the  reason  that  in  many  cases  the 
paralyses  clear  up  spontaneously  by  resorption  of  the 
haemorrhage.  Under  such  circumstances,  however,  the 
patient  must  be  watched  carefully,  and  if  the  compression 
symptoms  increase  in  severity,  operation  must  be  undertaken 
without  delay.* 

Contra-indications. — If,  after  a  head  injury,  signs  of 
compression  supervene  without  any  localizing  symptoms, 
and  if  no  bony  lesion  is  discoverable,  there  are  no  sufficient 
indications  for  operation.  In  such  a  case  operation  would 
only  be  done  in  the  hope  of  finding  the  source  of  the 
haemorrhage,  and  this  hope  is  exceedingly  unlikely  to  be 
realized. 

Prognosis. — Results  of  operation. — In  many  cases  the 
removal  of  clots,  and  the  discovery  and  ligature  of 
the  bleeding  vessel,  have  been  followed  by  complete 
recovery. 

Risks  of  operation. — These  must  be  considered  serious 
when  an  exact  diagnosis  of  the  situation  of  the  lesion  is 
wanting,  ■'^f When  the  site  of  the  haemorrhage  is  correctly 
diagnosed  the  risk  is  less. 

Results  without  operation. — The  haemorrhage  sometimes 
ceases  spontaneously,  and  after  remaining  stationary  for  a 
long  time,  the  symptoms  in  such  a  case  may  be  expected  to 
gradually  disappear.  If,  however,  the  symptoms  steadily 
become  more   severe,    the    intracranial    tension    increases. 


*  A  case  was  recently  recorded  by  Saenger  and  Grisson  in  which 
cortical  epilepsy  suddenly  appeared  four  days  after  a  head  injury  ; 
this  commenced  in  the  face  and  persisted.  Some  loss  of  consciousness 
supervened  later,  and  operation  was  then  done.  After  incision  of  the 
dura  a  hsematoma  overlying  the  central  convolutions  was  found  and 
removed.     Recovery  followed. 


DISEASES   OF   THE   BRAIN  AND   ITS   MENINGES.      35 

and  the  paralysis  extends,  unless  operation  is  undertaken 
death  will  follow  with  the  symptom-complex  of  cerebral 
paralysis. 

LITERATURE. 

Allen  Starr.     Brain  Surgery.      1893. 
Jacobson.     Guy's  Hospital  Reports.      1886. 
DuRET.     La  Semaine  Medicale.     April,  i8qi. 

WiESMANN.  Die  modernen  Indikationen  der  Trepanation. 
Deut.  Zeits.  f.  Chirurgie.     Bd.  xxi  and  xxii. 

TUBERCULAR    MENINGITIS. 

Etiology. — This  affection  is  almost  always  of  a  secondary 
character,  associated  especially  with  tuberculosis  of  the 
lungs,  glands,  bones,  and  joints. 

Pathological  Anatomy. — The  chief  characteristics  are 
the  occurrence  of  inflammatory  changes  in  the  pia  mater 
and  arachnoid,  the  development  of  tubercles  of  varying 
size  in  these  membranes,  and  the  accumulation  of  an 
excessive  amount  of  cerebrospinal  fluid  in  the  ventricles. 
The  membranes  at  the  base  of  the  brain  are  chiefly 
involved. 

Clinical  Course. — ^After  a  prodromal  stage  of  varying 
length,  during  which  the  patient  suffers  from  lassitude, 
headache,  and  irritability,  and  sometimes  a  transitory 
aphasia,  more  pronounced  signs  of  cerebral  irritation  begin 
to  make  their  appearance.  Such  signs  are  :  stiffness  of  the 
neck,  cutaneous  hypergesthesia,  inequality  of  the  pupils, 
photophobia,  headache,  delirium,  convulsions,  vomiting, 
slowing  or  irregularity  of  the  pulse.  Constipation  is  usual, 
and  retraction  of  the  abdomen,  and  Trousseau's  sign  {taches 
cerebrales)  may  be  present.  Flexion  of  the  hip  with  the  leg 
extended  causes  considerable  pain,  and  the  legs  cannot  be 
extended  in  the  sitting  posture  (Kernig's  sign).  A  slight 
elevation  of  temperature  is  almost  always  found.  After 
some  days  or  weeks  the  patient  becomes  comatose,  paralyses 
of  the  cranial  nerves  appear,  the  pupils  do  not  react,  and 
examination  of  the  fundus  oculi  shows  tubercles  in  the 
choroid.  The  pulse  rate  increases,  and  Cheyne-Stokes 
respiration  develops.  At  the  time  of  death  there  is  often 
marked  hyperpyrexia.  The  symptoms  are,  on  the  whole, 
very  variable  in  their  character  and  evolution. 

Diagnosis   and    Differential   Diagnosis. — The   earlv 


^6  INDICATIONS    FOR    OPERATION    IN 

appearance  of  rigidity  of  the  neck,  and  of  Kernig's  symptom, 
and  examination  of  the  fluid  obtained  by  lumbar  puncture, 
will  clear  up  the  diagnosis.  The  cerebrospinal  fluid  is 
turbid,  and  on  standing  a  scum  often  forms,  in  which 
tubercle  bacilli  may  be  found.  The  diagnosis  from  typhoid 
fever  (Widal's  reaction),  prevertebral  cellulitis,  acute 
infectious  diseases  with  meningeal  symptoms,  brain  tumour 
and  abscess,  and  cerebral  haemorrhage,  is  often  difficult, 
but  is  much  facilitated  by  lumbar  puncture. 

INDICATIONS   FOR   OPERATION. 

Of  the  different  operative  procedures  which  have  been 
tried  in  tubercular  meningitis  (puncture  of  the  lateral 
ventricles,  and  of  the  fourth  ventricle,  opening  and  drainage 
of  the  spinal  canal  by  laminectomy,  puncture  of  the  spinal 
canal)  spinal  puncture  alone  appears  to  be  justifiable.  This 
is  indicated  (a)  for  diagnostic  purposes  ;  (b)  to  relieve  or 
ameliorate  symptoms  of  severe  cerebral  compression.  The 
advice  which  has  been  given  by  several  authors  that  puncture 
should  be  undertaken  with  the  idea  of  gaining  time  for  the 
carrying  out  of  some  curative  treatment,  is  of  theoretical 
rather  than  of  practical  interest. 

Prognosis. — Results  of  spinal  puncture. — Headache  and 
other  pressure  symptoms  are  often  markedly  improved,  and 
the  patient  may  obtain  marked  relief  for  some  hours  or  even 
days.  I  have  often  practised  spinal  puncture  with  the  view 
of  affording  this  relief.  It  is  only  in  very  exceptional  cases 
(Freyhan),  and  then  only  by  repeated  puncture,  that 
recovery  or  considerable  prolongation  of  life  has  been 
obtained.  Puncture  must  thus  be  looked  upon  only  as  a 
means  of  relieving  certain  of  the  symptoms. 

The  risks  of  spinal  puncture  are  very  small  in  uncompli- 
cated tubercular  meningitis,  if  too  rapid  escape  of  fluid 
is  prevented,  and  if  the  operation  is  interrupted  on  the 
appearance  of  symptoms  of  collapse.  It  is  therefore  contra- 
indicated  in  a  relatively  small  number  of  cases.  Although 
lumbar  puncture  has  been  performed  in  a  large  number  of 
cases  by  myself  and  under  my  supervision,  I  have  never 
experienced  any  disagreeable  accident.  It  is  only  contra- 
indicated  when  the  patient  has  already  reached  the  stage  of 
paralysis,  and  when  the  general  condition  will  not  tolerate 
any  interference,  however  slight. 


DISEASES  OF   THE  BRAIN  AND   ITS   MENINGES.      37 

LITERATURE. 

Neurath.  Lumbalpunktion.  Zentralb.  f.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     1898. 

Freyhan.     Deut.  med.  Wochens.     1894,  No.  36. 
FiJRBRiNSER.     Berl.  klin.  Wochens.      1895,  ^o-  ^3- 

ACUTE    LEPTOMENINGITIS. 

Etiology. — The  disease  is  probably  always  due  to 
bacterial  infection.  The  organisms  reach  the  meninges 
either  from  some  distant  focus  by  metastasis,  or  directly 
from  some  inflammatory  lesion,  more  or  less  directly  in 
contact  with  the  meninges,  either  within  (brain  abscess)  or 
without.  Such  lesions  may  be  in  the  scalp,  the  ear,  the 
frontal  sinus,  the  nasal,  oral,  and  orbital  cavities,  etc. 

Pathological  Anatomy. — The  infection  makes  its  way 
through  lymph  and  blood  channels,  and  spreads  rapidly 
throughout  the  cerebral  and  spinal  meninges.  There  is  also 
a  localized  type.  The  exudation  may  be  either  serous, 
haemorrhagic,  or  purulent. 

Clinical  Course. — The  disease  usually  begins  acutely, 
with  fever,  rigors,  and  intense  headache,  and  vomiting. 
Consciousness  is  also  often  affected,  and  various  signs  of 
irritation  appear,  cutaneous  hypersesthesia,  headache,  photo- 
phobia, nystagmus,  muscular  spasm,  and  sometimes  con- 
vulsions. Rigidity  of  the  neck  and  Kernig's  sign  are 
specially  important,  the  latter  being  the  impossibility  of 
extending  the  legs  with  the  patient  in  the  sitting  posture. 
The  pulse  is  slowed,  and  the  pupils  are  unequal  or  contracted. 
Later,  paralyses  occur,  and  the  pulse-rate  increases,  and 
there  appear  strabismus,  dilatation  of  the  pupils,  paresis  of 
a  single  or  of  all  extremities,  Cheyne-Stokes  respiration, 
deep  stupor,  and  retention  or  incontinence  of  urine.  In 
epidemic  -  cerebrospinal  meningitis  there  is,  as  a  rule,  a 
diffuse  herpetic  eruption,  and  paresis  of  the  ocular  muscles 
is  often  an  early  symptom. 

The  serous  meningitis  of  Quincke  may  run  an  acute  or 
chronic  course  :  fever  is  intermittent  and  slight,  and  all 
the  symptoms  are  of  a  rather  subdued  type.  Purulent 
non-epidemic  meningitis,  on  the  other  hand,  usually 
exhibits  severe  symptoms  from  the  beginning,  and  relatively 
often  some  local  symptoms.  Non-suppurative  meningo- 
encephalitis often  follows  some  acute  infectious  disease,  and 


38  INDICATIONS    FOR    OPERATION    IN 

marked   irritative   or   paralytic   symptoms   are    frequently 
observed  from  the  commencement. 

Differential  Diagnosis. — The  condition  is  to  be 
differentiated  in  particular  from  tubercular  meningitis  and 
enteric  fever.  In  the  latter  there  is  no  slowing  of  the  pulse 
and  no  leucocytosis,  while  Widal's  reaction  is  positive.  In 
cerebral  tumour  the  course  is  apyrexic  ;  when  the  symptoms 
are  chronic  in  type  and  local,  and  when  definite  optic  neuritis 
is  present,  tumour  is  indicated.  Septic  processes  in  the 
vicinity  of  the  meninges  are  often  with  difficulty  differ- 
entiated from  meningitis,  and  are  indeed  often  associated 
with  the  latter.  If  rapid  improvement  takes  place  after  the 
evacuation  of  pus,  definite  meningitis  is  probably  absent. 
Tubercular  meningitis  is  distinguished  by  the  discovery  of 
the  bacilli  in  the  cerebrospinal  fluid. 

INDICATIONS   FOR   OPERATION. 

Operation  may  be  undertaken  as  a  prophylactic  measure, 
or  when  meningitis  is  fully  established.  All  accessible 
septic  foci  bordering  on  the  meninges  should  be  evacuated 
as  early  as  possible,  whether  meningitis  threatens  or  not. 
When  intracranial  pressure  threatens  life,  or  if  intense  and 
persistent  pain  is  complained  of  in  the  head  and  neck, 
lumbar  puncture  should  be  done,  and  may  be  repeated  if 
these  symptoms  reappear. 

With  regard  to  direct  operative  interference  in  meningitis 
by  trephining,  puncture  of  the  ventricles  or  of  the  meninges, 
clinical  experience  has  not  yet  been  sufficiently  great  to 
permit  of  the  formulation  of  indications. 

Contra-indications. — Lumbar  puncture  is  only  contra- 
indicated  when  the  patient  is  moribund. 

Prognosis. — Results  of  operation. — Localized  meningitis 
often  disappears  when  the  neighbouring  septic  focus  is  success- 
fully treated.  Lumbar  puncture  often  brings  about  a  marked 
relief  to  the  symptoms  of  cerebral  compression  ;  sometimes 
this  relief  is  only  of  short  duration,  but  the  puncture  may 
be  repeated.  Occasionally  lumbar  puncture  has  a  curative 
influence.* 


*  Recently,  in  a  case  of  hsemorrhagic  meningo-encephalitis,  under 
my  care,  lumbar  puncture  was  repeated  three  times.  Marked  improve- 
ment resulted,  although  the  patient  was  extremely  ill,  and  he  ultimately 
recovered. 


DISEASES  OF  THE  BRAIN  AND   ITS  MENINGES.     39 

Risks  of  operation. — If  too  much  fluid  is  not  removed,  and 
it  is  not  allowed  to  run  too  fast,  the  dangers  of  lumbar 
puncture  are  minimal,  even  if  the  foramen  of  Magendie  is 
obstructed. 

//  no  operation  is  undertaken,  death  from  cerebral  com- 
pression is  to  be  expected. 

LITERATURE. 

Henschen.  Hirnkrankheiten.  Handbuch  der  spez.  Therap. 
von  Penzoldt-Stintzing.     Jena.     2nd  Ed. 

Quincke.  Meningitis  Serosa.  Volkmann's  Hefte,  Neue  Folge, 
No.  67. 

Neurath.  Lumbalpunktion.  Zentralb.  f.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     i8q8. 


CHAPTER    11. 
Diseases   of  the    Spinal    Column    and   Cord. 


43 


Chapter    II. 

DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD. 

TUBERCULAR   SPONDYLITIS  (Pott's  Disease). 

Etiology. — The  various  etiological  factors  which  influence 
the  development  of  tubercular  disease  are  concerned  in  the 
etiology  of  tuberculosis  of  the  spinal  column.  Injury  is  an 
etiological  factor  of  some  importance. 

Pathological  Anatomy. — The  disease  is  somewhat 
frequently  discovered  at  post-mortems.  Out  of  35,000 
autopsies  at  the  Pathological  Institute  in  Vienna,  it  was 
found  in  420  instances.  The  vertebral  bodies  are  much 
more  frequently  affected  than  the  vertebral  arches,  and  the 
process  gives  rise  to  destructive  lesions  by  caseation  and 
caries.  When  a  vertebra  is  destroyed  and  those  on  each 
side  are  also  involved,  a  kyphosis  is  developed,  with  an 
angular  projection  corresponding  to  the  carious  segment. 
The  thorax  and  pelvis  both  undergo  considerable  secondary 
changes  in  form.  The  ventral  portion  of  the  vertebral  body 
being  usually  chiefly  affected,  pus,  when  formed,  usually 
passes  forwards  between  the  centrum  and  the  anterior 
common  ligament.  Abscesses  from  high  cervical  disease 
usually  present  behind  or  to  one  side  of  the  pharynx 
or  oesophagus,  or  make  their  way  into  the  posterior 
mediastinum.  In  dorsal  disease  the  abscess  may  point 
behind  directly  over  the  lesion,  or  come  forwards  into 
the  pleura  or  lung,  or,  more  commonly,  enter  the 
sheath  of  the  psoas  muscle.  Abscesses  associated  with 
lumbar  disease  pass  into  the  loin,  the  iliac  fossa,  or 
the  pelvis.  In  many  cases  the  course  of  the  abscess  is 
aberrant,  and  perforation  may  occur  into  the  oesophagus, 
trachea,  intestine,  and  bladder.  Sometimes  there  is  a 
bilateral  abscess  cavity,  usually  communicating  the  one  side 
with  the  other.  The  spinal  cord  is  often  compressed  by 
collections  of  pus,  or  by  tubercular  granulation  tissue, 
arising  from  the  bone  disease  or  from  the  spinal  dura  mater. 


44  INDICATIONS    FOR    OPERATION    IN 

According  to  Trendelenburg,  it  is  only  in  rare  instances  that 
compression  is  due  to  the  bone  impinging  on  the  cord.  On 
an  average,  compression  of  the  cord  occurs  once  in  nine 
cases. 

Clinical  Course. — The  disease  often  remains  long  latent. 
The  first  symptoms  may  be  attributable  to  [a)  The  bone 
disease  itself  ;  {h)  The  involvement  of  the  cord  and  nerve 
roots  ;  (c)  The  development  of  an  abscess  ;  or  {d)  The  effect 
of  the  disease  on  the  general  health.  Pain  is  one  of  the  most 
important  and  early  symptoms.  It  is  sometimes  only  com- 
plained of  in  one  position,  standing  or  lying  down,  and  is 
often  very  severe  and  of  a  throbbing  character.  Sometimes 
it  is  spontaneous,  but  more  frequently  it  is  only  complained 
of  when  pressure  is  brought  to  bear  on  the  affected  vertebrae 
•by  pressing  on  the  head  or  shoulders  (this  manoeuvre  must 
be  cautiously  carried  out),  and  is  referred  to  the  situation  of 
the  disease.  Hot  local  applications  and  the  galvanic  current 
also  bring  out  this  symptom  of  local  tenderness.  Rigidity 
of  the  spine  is  a  sign  of  importance,  due  to  muscular  con- 
traction, or,  in  some  instances,  to  anatomical  bone  changes, 
and  best  seen  when  the  patient  stoops  and  rises.  This 
rigidity  is  often  transitory,  and  may  be  mistaken  for 
"  rheumatism  ;  "  a  transitory  torticollis  in  a  young  subject 
should  always  make  one  suspect  spondylitis.  When  situated 
in  the  upper  cervical  region  the  patient  often  supports  his 
head  with  his  hands.  Any  sudden  movement  is  very 
painful. 

Destruction  of  one  or  more  vertebral  bodies  results  in 
angular  curvature  ;  if  the  caries  affects  one  side  more  than 
another,  a  lateral  may  be  added  to  the  antero-posterior 
deformity.  Occasionally  there  is  more  than  one  such 
curvature.  Swelling  of  the  surrounding  soft  parts  may 
make  the  deformity  still  more  pronounced,  and  sometimes, 
in  children,  simulates  a  vertebral  tumour,  especially  in  the 
lumbar  region. 

General  symptoms  accompany  the  development  of  the 
bone  disease  :   fever,  profuse  sweating,  loss  of  flesh,  etc. 

Retropharyngeal  abscess  may  interfere  with  respiration 
and  deglutition.  Psoas  abscesses  destroy  the  muscle  and 
cause  flexion  of  the  corresponding  thigh  ;  later  they  appear 
in  the  iliac  fossa,  or  the  groin,  more  rarely  in  the  back. 

The    nervous    phenomena    are :    neuralgia,    and    hyper- 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     45 

aesthesia,  due  to  pressure  on  the  nerve  roots,  or  a  plexus  ; 
and,  in  a  later  stage,  paresis  or  paralysis  below  the  lesion 
due  to  compression  of  the  cord.  Paraplegia  of  the  lowei 
limbs  is  usually  associated  with  rigidity  and  with  exaggera- 
tion of  the  tendon  reflexes  ;  the  skin  reflexes  are  retained 
or  exaggerated.  Girdle  pain  is  often  complained  of  ;  the 
functions  of  bladder  and  rectum  are  often  affected.  When 
cord  conduction  is  completely  abolished  there  is  anaesthesia 
of  the  parts  below  as  far  up  as  the  affected  spinal  segment  ; 
above  the  aucesthetic  area  there  is  often  a  hyperaesthetic 
zone.  When  the  disease  is  situated  in  the  lowest  dorsal 
region  the  paralysis  is  flaccid,  not  spastic.  When  the  lower 
cervical  vertebrae  are  affected  there  will  be  atrophic  paralysis 
of  the  arms,  with  spastic  paresis  of  the  legs.  Paralysis  in 
suboccipital  disease  will  include  bulbar  symptoms. 

Diagnosis  and  Differential  Diagnosis. — In  well- 
marked  cases  the  diagnosis  presents  no  difficulties,  but  in 
others  these  are  considerable.  A  radiograph  affords 
valuable  assistance.  Relatively  often  the  disease  is  mistaken 
for  vertebral  tumour  in  its  early  stages.  In  the  latter  con- 
dition the  pain  is  usually  much  more  severe  and  more 
continuous  ;  the  deformity  caused  by  tumour  is  not  the 
acute  angular  curvature  of  spondylitis. 

The  traumatic  spondylitis  of  Kiimmel  develops  after  a 
period  varying  from  a  month  to  a  year  after  an  injury  to  the 
spinal  column  ;  an  angular  deformity  develops,  with  symp- 
toms of  compression  of  the  cord  and  pain  ;  but  after  some 
time  recovery  follows,  or  at  least  the  condition  becomes 
stationary. 

INDICATIONS   FOR   OPERATION. 

It  must  first  be  stated  that  there  is  no  uniformity  of 
opinion  on  the  indications  for  surgical  interference  in  this 
disease,  but  the  majority,  both  of  surgeons  and  physicians, 
recommend  conservative  methods,  and  only  advise  opera- 
tion for  the  relief  of  paralysis,  abscess,  and  other  com- 
plications. 

For  the  relief  of  paralysis  there  are  only  two  procedures 
which  need  be  discussed  :  laminectomy,  and  the  forcible 
correction  of  angular  curvatures. 

Laminectomy  is  performed  for  the  direct  treatment  of 
vertebral    caries,    particularly    when    paralysis    is    present. 


46  INDICATIONS    FOR    OPERATION    IN 

Experience  has  shown  that  the  actual  bone  disease  cannot 
as  a  rule  be  removed ;  only  the  masses  of  tubercular 
granulation  tissue  can  be  dealt  with,  and  intradural  abscesses 
opened.  Oppenheim  has  expressed  his  views  on  the  subject 
as  follows  :  "  Laminectomy  is  called  for  in  compression 
paralysis  (a)  In  the  exceptional  cases  of  caries  of  the 
vertebral  arch  when  conservative  treatment  has  failed  ; 
(b)  When,  in  opening  an  abscess,  direct  access  is  found  to  be 
obtainable  to  the  affected  vertebral  body."  Schede, 
Tillmanns,  and  Trendelenburg  have  also  formulated  indica- 
tions for  this  operation.  Schede  considers  laminectomy 
only  a  last  resource,  "  when  the  condition  of  the  patient  is 
desperate  "  (Vulpius).  Tillmanns  advises  it  when  palliative 
treatment  has  failed,  in  cases  where  high  fever  indicates  the 
presence  of  pus,  or  where  paralysis  persists.  Trendelenburg, 
in  addition  to  these,  recommends  operation  in  old-standing 
cases  in  which  an  incomplete  paralysis  persists. 

Calot's  method,  the  forcible  reduction  of  angular  curvature, 
is  hardly  ever  now  employed  in  the  form  in  which  it  was 
introduced  ;  gradual  reduction  is  practised  by  some  surgeons, 
and  appears  particularly  advisable  in  cases  in  which 
paralysis  of  a  severe  type  is  present. 

When  an  abscess  is  retropharyngeal  in  position,  and 
obstructs  respiration,  it  should  be  opened  ;  for  abscesses 
in  other  situations,  puncture,  followed  by  iodoform  and 
glycerin  injection,  is  the  best  method  (Henle,  Vulpius). 

Contra-indications. — In  acute  tubercular  processes  all 
operations  are  contra-indicated,  except  the  treatment  of 
abscess.  No  operation  for  curvature  or  paralysis  should  be 
undertaken  unless  palliative  treatment  has  been  given  a 
long  trial  and  been  found  ineffective,  and  no  operation  of 
any  kind  should  be  done  when  there  is  marked  tuberculosis 
of  other  organs,  advanced  renal  disease,  an  unsatisfactory 
general  condition,  or  other  like  complication. 

Prognosis. — The  results  and  risks  of  operation. — The 
operative  treatment  of  cases  of  spondylitis  has  given 
generally  disappointing  results,  and  the  limits  of  indication 
have  been  correspondingly  narrowed.  Chipault's  statistics 
of  103  cases  of  laminectomy  showed  only  fifteen  recoveries, 
and  forty-three  deaths  soon  after  the  operation.  Cases  of 
severe  paralysis  may  improve  or  recover  entirely  after 
gradual  correction  of  the  deformity,  or  laminectomy,  if  the 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     47 

bone  disease  is  not  of  a  very  active  type.     Cold  abscesses 
often  subside  or  disappear  after  iodoform  injection,     f  c 

Without  operation. — Complete  rest,  immobilization,  ex- 
tension, and  the  plaster  jacket  often  bring  about  recovery. 
Many  times  I  have  seen  paralysis  of  all  four  extremities 
recover  under  treatment  with  the  plaster  jacket.  Oppen- 
heim  has  recorded  recovery  to  the  extent  of  being  able  to 
walk,  in  a  case  of  paraplegia  of  seven  years'  standing. 
About  half  the  cases  may  be  expected  to  recover  with  the 
use  of  orthopaedic  apparatus. 

LITERATURE. 

VuLPius.  Die  moderne  Behandlung  der  Spondylitis.  Zentralb. 
f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1899. 

Henle.  Spondylitis.  Handb.  d.  prakt.  Chir.,  von  Bergmann, 
Bruns,  md  Mikulicz.     Bd.  II.,  1900. 

Oppenheim.  Lehrbuch  d.  Nervenkrankheiten.  3rd  Ed.,  Berlin, 
1902. 

LoRENZ.     Spondylitis.     Realencyklop.  d.  Heilkunde.      3rd  Ed. 

Krause.  Tuberkulose  der  Knochen  u.  Gelenke.  Deutsche 
Chirurgie,  28a. 


OSTEOMYELITIS  OF  THE  YERTEBRiE. 

Etiology. — Infection  with  staphylococcus  aureus  and 
albus,  as  in  osteomyelitis  of  other  bones.  Trauma  is  a 
causative  agent  in  a  relatively  large  proportion  of  cases. 

Pathological  Anatomy. — The  lumbar  vertebrae,  and 
next,  the  dorsal  vertebras,  are  the  most  frequently  affected. 
Sometimes  one,  sometimes  several  vertebrse  are  attacked, 
and  either  the  centrum,  or  the  arch,  or  spinous  process  may 
be  involved.  The  sequestrum  may  be  of  such  a  size  that 
an  angular  curvature  is  formed.  Pus  may  compress  the 
cord,  or  point  under  the  skin  of  the  back,  or  behind  the 
pharynx.     Sometimes  a  psoas  abscess  is  formed. 

Clinical  Course.  This  rare  affection  usually  begins 
acutely  with  symptoms  of  general  constitutional  disturbance, 
high  fever,  and  frequently  rigors.  Sometimes,  but  rarely, 
the  onset  is  more  gradual.  Tenderness  of  the  affected 
vertebrae,  with  rigidity,  appears  early.  At  the  end  of  the 
first  week  there  is  marked  inflammatory  swelling  of  the 
tissues  of  the  back,  at  the  site  of  the  disease,  going  on  to 
abscess  formation.  If  the  vertebral  bodies  are  affected,  a 
retropharyngeal  abscess  forms  if  the  disease  is  cervical ; 


48  INDICATIONS    FOR    OPERATION    IN 

but  if  it  is  situated  lower,  an  abscess  forms  which  may  burst 
into  the  pleura,  and  is  hardly  recognizable  clinically. 

Diagnosis.— The  diagnosis  may  sometimes  be  made  when 
severe  constitutional  symptoms  are  present,  with  localized 
tenderness  over  the  spine,  inflammatory  oedema,  and  abscess. 
The  disease  is  more  easily  recognized  when  it  affects  the 
laminae  and  spines,  than  when  the  centra  are  involved. 

INDICATIONS    FOR    OPERATION. 

Operation  should  be  undertaken  immediately  the  diagnosis 
has  been  made.  Pus  is  evacuated,  and,  when  possible,  the 
diseased  bone  is  removed. 

Risks  of  operation. — These  are  greatest  when  operation 
has  been  delayed  ;  the  condition  of  the  patient  will  be  then 
more  unsatisfactory  and  the  operation  more  extensive. 

Prognosis. — //  }io  operation  is  performed  death  will 
probably  take  place,  the  total  mortality  of  all  cases, 
including  those  successfully  operated  on,  being  over  60 
per  cent.  At  the  best,  a  prolonged  illness,  with  probably 
amyloid  disease,  is  to  be  expected. 

Results  of  operation. — In  most  cases  the  disease  has  been 
cut  short  by  operation,  with  recovery  ;  sacral  osteomyelitis 
nas,  however,  up  to  the  present,  given  bad  results. 

LITERATURE. 

Hahn.  Die  akute  infektiose  Osteomyelitis  der  Wirbel.  Beitr 
z.  klin.  Chir.,  Bd.  xxv.  p.,  176. 

TRAUMATIC  AFFECTIONS  OF  THE  SPINAL  CORD. 

Etiology. — Traumatic  affections  of  the  spinal  cord 
result  from  direct  or  indirect  violence  to  the  spinal  column  ; 
actual  lesions  of  the  latter  may  or  may  not  be  present  in 
association. 

Pathological  Anatomy. — Trauma  may  give  rise  to 
severe  and  extensive  destruction  of  the  spinal  cord,  especially 
of  its  central  parts,  by  necrosis  and  haemorrhage,  without 
any  discoverable  lesion  of  the  spinal  column,  such  as  fracture 
or  dislocation,  or  of  the  meninges.  On  the  other  hand  the 
cord  may  be  markedly  compressed  by  a  detached  bone 
splinter  or  a  dislocated  vertebra  without  any  notable 
change  in  its  structure,  even  when  the  lesion  has  existed  for 
several  months.     Speaking  generally,  however,  injuries  of 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     49 

the  spinal  column  are  usually  complicated  by  lesions  of  the 
cord.  In  100  cases  collected  by  Wagner  and  Stolper,  the 
cord  was  involved  in  seventy-one,  unaffected  in  twenty-nine. 
It  is  often  completely  pulped  at  the  point  of  greatest 
compression.  Epidural  haemorrhages  are  common  and  often 
very  extensive,  but  do  not  as  a  rule  cause  compression 
of  the  cord.  The  nerve  roots  are  very  rarely  destroyed, 
compressed,  or  damaged  by  bone  splinters.  They  are 
usually  compressed  along  with  the  cord  when  the  latter 
is  pulped,  either  at  their  attachment  or  in  their  course 
through  the  intervertebral  foramina.  Occasionally,  but 
rarely,  the  cord  is  compressed  by  callus  thrown  out 
after  fracture  or  by  connective  tissue  formed  at  the  site  of 
meningeal  lesions. 

Clinical  Signs. — These  may  be  divided  into  two  groups  ; 
the  first  comprising  those  which  are  due  to  anatomical 
changes  in  the  spinal  column,  the  second  those  which  belong 
to  the  nervous  system.  Luxation  may  be  complete  or 
incomplete,  unilateral  or  of  both  intervertebral  joints. 
As  a  rule  defo;mity  can  be  made  out  by  palpation  or  by 
X-ray  examination  ;  it  may  show  itself  as  a  displacement 
forwards  of  a  spinous  process,  and  in  the  neck  a  prominence 
may  be  felt  on  palpation  of  the  pharyngeal  wall.  In 
unilateral  dislocations  the  spine  is  rotated  with  the  con- 
vexity on  the  side  of  the  displacement.  Dislocations  are 
most  common  in  the  cervical  and  rarest  in  the  lumbar 
regions. 

Fracture  gives  rise  to  very  similar  deformities.  Occasion- 
ally detached  bony  fragments  can  be  palpated.  Radio- 
graphy is  of  great  value.  In  one  of  my  own  cases  a  radio- 
graph showed  a  bony  lesion  unrevealed  by  any  other  sign, 
the  case  being  apparently  a  pure  cord  lesion.  Fracture 
is  most  common  in  the  lower  dorsal  and  upper  lumbar 
regions.  The  combination  of  total  luxation  with  fracture 
is  comparatively  common,  especially  in  the  lower  dorsal 
segment. 

In  some  cases  of  fracture-dislocation  the  cord  escapes. 
When  it  is  involved,  the  symptoms  may  indicate  a  complete 
or  an  incomplete  interruption  of  conduction.  Complete 
interruption,  whether  due  to  pulping,  haemorrhage, 
necrosis,  laceration,  or  compression,  is  characterized  by 
the  following  signs  : — 

4 


50  INDICATIONS    FOR    OPERATION    IN 

1.  Loss  of  cutaneous  sensibility  in  the  areas  whose 
sensory  nerves  reach  the  cord  below  or  at  the  level  of  the 
cord  lesion.  The  area  of  anaesthesia  does  not,  however, 
extend  as  far  upwards  as  the  vertebra  concerned ;  its  upper 
level  is  usually  below  this,  even  when  one  takes  into  account 
the  fact  that  the  spinous  process  which  projects  backwards 
does  not  usually  belong  to  the  vertebra  which  is  causing 
the  compression.  This  difference  in  level  between  the  bone 
lesion  and  the  area  of  anaesthesia  is  due  to  the  oblique 
course  which  the  spinal  nerves  pursue  in  the  spinal  canal, 
and  to  the  fact  that  they  usually  escape  injury  at  the  site 
of  the  fracture-dislocation.  The  nearer  the  latter  is  to  the 
point  where  the  cord  ends,  the  more  marked  is  the  difference 
between  the  levels  of  the  lesion  and  the  anaesthesia. 

2.  Flaccid  paralysis  of  the  muscles  whose  motor  nerves 
leave  the  cord  below  or  on  a  level  with  the  lesion.  Only 
the  muscles  innervated  from  the  spinal  segment  or  segments 
destroyed  undergo  atrophy. 

3.  The  motor  and  sensory  paralysis  is  congruent  and 
symmetrical. 

4.  The  patellar  reflexes  are  at  once  lost  and  remain 
absent. 

5.  Interference  with  the  functions  of  the  bladder  and 
rectum  is  the  rule  ;    renal  affections  are  common. 

6.  Vasomotor  paralysis  is  present  and  coterminous  with 
the  motor  and  sensory  paralysis.  Wagner  and  Stolper 
emphasize  three  signs  as  being  diagnostic  of  a  total  trans- 
verse lesion  of  the  cord.  (a)  The  congruence  and 
symmetry  of  motor  and  sensory  paralysis,  (b)  The  absence 
of  any  signs  of  irritability  in  the  paralyzed  area,  (c)  The 
loss  of  the  patellar  reflexes. 

The  same  authors  look  upon  the  following  as  indicative 
of  a  partial  cord  lesion  : — 

1.  When  the  motor  paralysis  and  the  sensory  paralysis 
do  not  coincide  in  extent. 

2.  When  the  paralysis  is  not  symmetrical. 

3.  When  there  are  signs  of  irritation,  either  motor  or 
sensory,  in  the  paralyzed  area. 

4.  Retention  of  the  patellar  reflexes  ;  these  are  rarely 
abolished  in  incomplete  lesions,  are  usually  exaggerated, 
often  differ  on  the  two  sides,  and  never  remain  permanently 
absent. 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     51 

5.  When  the  paralysis  lessens  in  degree,  or  sets  in  late, 
or  is  incomplete  in  both  motor  and  sensory  spheres. 

6.  When  function  is  either  completely  or  partly  restored 
in  the   first   or  second  week. 

Compression  of  posterior  roots  is  shown  by  the  presence 
of  radiating  pains,  and  by  hypersesthetic  or  anaesthetic 
spots  in  the  corresponding  skin  areas.  Phenomena  of 
motor  irritation  (twitching,  spasm)  or  of  atrophic  paresis 
in  the  muscles  point  to  compression  of  anterior  roots 
through  which  the  muscles  concerned  derive  their  nerve 
supply.  When  the  vertebral  lesion  is  below  the  second 
lumbar  level  the  cauda  equina  alone  will  be  involved. 
Lesions  of  the  latter  can  hardly  be  differentiated  from 
lesions  of  the  conus  terminalis.  In  cauda  lesions,  how- 
ever, phenomena  of  sensory  irritation  are  relatively 
common,  and  the  paralyses  are  often  unsymmetrical  and 
incomplete,  while  in  conus  lesions  there  is  symmetry,  and 
complete  paralysis  is  more  frequent. 

Differential  Diagnosis. — There  may  be  some  difficulty  in 
differentiating  these  lesions  from  spinal  concussion  without 
vertebral  injury ;  indeed,  according  to  Kocher,  there  is 
always  some  traumatic  necrosis  or  haematomyelia  in 
concussion.  Rapid  retrogression  of  symptoms  will  show 
that  there  is  no  necessity  for  operation.  Traumatic 
spondylitis  (Kiimmel),  which  appears  some  time  subsequently 
to  trauma,  with  pain,  rigidity,  and  signs  of  compression  of 
the  cord,  is  always  associated  with  the  development  of  an 
angular  curvature,  and  spontaneous  recovery  occurs  when 
the  patient  is  kept  at  rest. 

Latent  and  stationary  Pott's  disease  may  be  aggravated 
by  trauma  with  the  development  of  symptoms  pointing  to 
compression  of  the  cord,  and  the  same  is  true  of  cases  of 
vertebral  neoplasm.  A  benign  tumour  in  the  spinal  canal 
can  hardly  be  distinguished  from  exuberant  vertebral 
callus.  A  malignant  tumour  progresses  rapidly  and  gives 
rise  to  persistent  agonizing  pain,  while  the  pain  associated 
with  vertebral  injuries  gradually  lessens  in  intensity. 
There  can  rarely  be  any  confusion  with  vertebral  tubercu- 
losis. Crushing  of  the  intervertebral  disc  is  to  be  recognized, 
according  to  Kocher,  by  local  pain  on  pressure  on  the  head 
or  shoulders,  and  tenderness,  swelling,  and  prominence 
over  the  spines  immediately  above. 


52  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS   FOR  OPERATION. 

At  present  there  is  no  agreement  as  to  the  indications 
for  surgical  intervention  in  cases  of  fractured  spine.  It  is 
agreed,  however,  that  laminectomy  is  advisable  in  cases  of 
some  standing,  when  the  symptoms  are  those  of  incomplete 
interruption  of  cord  conduction.  Quite  recent  cases  should 
not  be  operated  on,  for  the  early  symptoms  may  clear  up 
spontaneously  to  a  very  great  extent*. 

Too  long  delay  may,  however,  result  in  irreparable 
damage  to  the  cord.  Most  writers  advise  operation  when 
symptoms  persist,  not  earlier  than  the  fifth  week,  and  not 
later  than  the  third  month  after  the  accident.  Early 
operation  is,  on  the  other  hand,  to  be  recommended  when 
there  is  a  comminuted  fracture  of  the  vertebral  arches, 
with  depression  and  probable  damage  to  the  cord  ;  also  in 
irreducible  fracture-dislocations  in  the  region  of  the  cauda 
equina,  and  in  cord  lesions  produced  by  firearms  and  sharp 
instruments. 

In  fractures  which  do  not  belong  to  one  or  other  of  these 
types,  few  surgeons  at  the  present  time  advise  early 
operation,  though  at  one  time  it  had  many  advocates 
(Wagner,  Chipault,  Lejars,  Biddle,  Hammond,  and  others). 

In  cases  of  persistent  paralysis,  when  there  is  a  deformity 
pointing  to  fracture  of  the  vertebral  arch,  laminectomy  is 
indicated.  It  is  also  recommended  by  many  authors, 
even  when  there  is  no  obvious  deformity,  in  cases  in  which 
the  paralysis  is  not  old-established,  when  compression  seems 
probable,  and  cord  conduction  is  not  completely  interrupted. 

If  paralysis  come  on  some  weeks  or  months  after  the 
fracture,  and  appear  to  be  due  to  cord  compression,  an 
exploratory  laminectomy  should  be  done  with  the  idea  of 
dealing  with  exuberant  callus,  or  adhesions  between  the 
meninges  and  the  more  or  less  displaced  vertebra. 

In  luxations,  reposition  should  be  done  as  far  as  possible. 
Laminectomy  should,  according  to  Chipault,  be  done  only 
in  old-standing  luxation  with  slight  symptoms.     Kirmisson, 


*  In  one  of  my  cases  a  fall  from  a  great  height  was  followed  by  motor 
and  sensory  paralysis  of  the  lower  limbs.  Examination  pointed  to 
a  probable  fracture  of  the  first  lumbar  vertebra.  The  paralysis  gradually 
disappeared  spontaneously  and  had  gone  completely  at  the  end  of 
about  a  year. 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     53 

however,  advises  it  when  the  attempts  at  reposition  have 
proved  unsuccessful,  but  the  symptoms  must  be  of  a 
certain  degree  of  severity  to  justify  the  operation. 

Contra-indications. — When  the  symptoms  point  to 
complete  local  destruction  of  the  cord,  no  operation  should 
be  done.  Persistent  complete  loss  of  cord  conduction  is, 
therefore,  a  contra-indication.  From  what  has  been  said 
already  it  will  be  gathered  that  I  consider  no  operation 
is  called  for  in  recent  cases,  nor  in  cases  of  some  years' 
standing  in  which  the  paralysis  is  stationary. 

Prognosis. — //  operation  he  undertaken. — Hahn  has  col- 
lected sixty-four  cases  of  laminectomy  for  vertebral  fracture, 
recorded  between  the  years  1893  and  1897.  In  30  per  cent 
recovery  or  improvement  resulted  ;  in  19  per  cent  the 
improvement  was  insignificant  ;  in  12  per  cent  there  was 
no  change  ;  and  in  39  per  cent  death  occurred.  The  results 
were  most  unfavourable  (66  per  cent  fatalities)  in  cervical 
and  high  dorsal  fractures,  and  most  successful  in  lumbar 
fractures.  There  is  no  doubt  that  in  a  not  inconsiderable 
number  of  cases  operation  has  been  harmful ;  it  should, 
therefore,  only  be  recommended  when  the  indications  are 
clear.  On  the  other  hand,  one  must  not  lose  sight  of  the 
fact  that  in  a  certain  number  of  cases  complete  success 
has  been  attained,  cases  which,  left  to  themselves,  would 
have  remained  paraplegic  all  their  lives,  and  died  at  an 
earlier  age. 

When  no  operation  is  undertaken  in  suitable  cases,  the 
patient  is  condemned  to  a  condition  of  permanent  marasmus, 
and  to  the  risks  of  life  which  arise  from  cystopyelitis, 
pressure-sores,  and  other  complications.  Operation  also 
may  be  delayed  too  long  to  stay  the  progress  of  degeneration 
processes  in  the  spinal  cord. 

LITERATURE. 

F.  Hahn.  Die  traumatischen  Erkrankungen  der  Wirbelsaule. 
Sammelref.  Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1898. 

KocHER  Die  Verletzungen  der  Wirbelsaule.  Mittelungen  aus 
d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  i. 

Wagner  und  Stolper.  Die  Verletzungen  der  Wirbelsaule. 
Deut.  Chirurgie.     Stuttgart.      1898. 

Thorburn.  a  Contribution  to  the  Surgery  of  the  Spinal  Cord. 
London.      1889. 

Goldscheider.  Ueber  Chirurgie  bei  Riickenmarkskrankheiten. 
Deut.  med.  Wochens.      1894,     Hf.  29. 


54  INDICATIONS    FOR    OPERATION    IN 

Henle.  Wirbelkrankheiten.  Handbuch  d.  prakt.  Chirurgie. 
von  Bruns,  Mikulicz,   u.   Bergmann.     Stuttgart :  Enke.        --^ 

Chipault.     Chirurgie  Oper.  du  Systeme  Nerveux.     Paris.      1895. 

KuMMEL.  Ueber  die  traumatischen  Erkrankungen  der  Wirbel- 
saule.     Deut.  med.  Wochens.     Bd.  xxi. 


TUMOURS  OF  THE  SPINAL  CORD. 

Pathological  Anatomy. — The  term  "  tumours  of  the 
spinal  cord  "  is  intended  to  include  both  tumours  originating 
in  the  cord,  and  those  which  originate  outside  the  cord  and 
compress  it.  Only  the  latter  are  suitable  for  operation  ; 
they  may  be  either  intradural  or  extradural.  Of  the 
intra  vertebral  growths  the  intradural  are  about  as  frequent  as 
the  extradural  ;  tumours  of  the  vertebrae  encroaching  on 
the  cord  are  twice  as  common  as  all  other  meningeal  and 
medullary  tumours  together.  Most  common  are  the 
extramedullary  tumours  of  the  dorsal  region.  Metastatic 
growths,  both  carcinomata  and  sarcomata,  are  almost 
always  extramedullary.  Meningeal  growths  are  usually 
primary,  and  more  often  malignant  than  benign  ;  tumours 
of  the  vertebrae  are  almost  always  malignant.  The 
meningeal  tumours  very  rarely  infiltrate  the  cord ;  usually 
they  simply  compress  the  latter  from  outside.  The  most 
common  extramedullary  tumours  (sarcoma,  psammoma, 
endothelioma,  hydatid,  fibroma,  etc.)  are  well  defined. 
Some  types  (sarcoma,  neurofibroma,  gumma,  hydatid), 
may  be  multiple  or  diffuse  ;  diffuse  sarcomatosis  is  usually 
associated  with  growth  in  the  cerebellum.  Multiple  tumours 
are  much  less  common  than  single  growths.  Trauma 
appears  to  favour  the  development  of  spinal  tumours. 

Clinical  Course. — In  many  cases  the  clinical  phenomena 
make  their  appearance  in  a  definite  order.  The  first  signs 
are  those  of  irritation  of  the  nerve  roots ;  then  follow  those 
of  compression  of  the  cord,  at  first  on  the  same  side  as  the 
root  irritation  phenomena,  and  later  bilateral.  Lastly  (but 
sometimes  early)  localized  pains  appear,  and  sometimes 
vertebral  deformity. 

Irritation  of  the  nerve  roots  is  shown  chiefly  by  intense 
neuralgic  pains,  usually  unilateral,  sometimes  bilateral ; 
the  pains  being  associated  with  hyperaesthesia.  If  the 
tumour  is  situated  on  an  anterior  root  in  the  cervical  or 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     55 

lumbar  enlargements,  there  are  motor   disturbances,  soon 
followed  by  muscular  atrophy. 

As  the  condition  progresses  hypersesthesia  may  be  replaced 
by  anaesthesia,  or  the  most  prominent  change  may  be  an 
extension  of  the  area  of  hyperaesthesia  or  anaesthesia. 
The  vertebral  column  may  show  rigidity.  Usually  the  root 
symptoms  are  rapidly  followed  by  those  of  cord  compression. 
These  take  the  form  of  spastic  paresis  of  the  extremities, 
often  at  first  on  one  side,  and  later  on  both.  Tumours 
low  down  will  affect  only  the  lower  limb,  cervical  tumours 
will  affect  both  upper  and  lower.  At  this  stage  the  symptoms 
resemble  transitorily  those  of  Brown-Sequard's  paralysis. 
When  complete  paraplegia  develops,  the  bladder  and  rectum 
functions  are  disturbed,  or  this  may  occur  at  an  earlier 
stage.  The  intense  neuralgic  pains  persist  along  with  the 
signs  of  cord  compression. 

The  symptoms  vary  very  much  according  to  the  site  of 
the  tumour,  and  no  detailed  description  can  be  given  here. 
The  exact  position  of  tumours  near  the  caudal  end  of  the 
cord  may  be  very  difficult  to  diagnose.  When  the  symptoms 
point  to  the  involvement  of  nerve  roots  or  cord  segments 
at  different  levels,  the  case  is  probably  one  of  multiple 
tumour.  In  one  of  my  cases  a  tumour  was  diagnosed 
about  the  centre  of  the  dorsal  spine,  and  operation  was 
advised  ;  later,  symptoms  referable  to  the  lumbar  spine 
appeared,  multiple  tumour  was  diagnosed,  and  no  further 
operation  was  recommended.  The  autopsy  showed 
multiple  neurofibromata. 

Diagnosis. — One  must  seek  to  establish  not  only  the 
presence,  but  also  the  exact  position  of  a  tumour.  The 
position,  or  rather  its  upper  limit,  can  usually  be  accurately 
determined  by  observing  the  phenomena  of  irritation  and 
paralysis  caused  by  lesion  to  the  nerve  roots  and  cord. 
Neurological  works  should  be  consulted  for  further 
information  on  localization. 

Differential  diagnosis. — Tumour  may  most  easily  be  con- 
fused with  vertebral  caries  ;  in  the  latter  the  curvature  is 
angular  and  acute,  not  arched  ;  the  presence  of  abscess  and 
of  tuberculosis  in  other  organs,  the  tendency  to  spontaneous 
recovery,  and  the  absence  of  persistent  nerve  root  symptoms 
point  to  caries.  The  presence  of  a  primary  growth  elsevv^here, 
of    S])ontaneous    fractures    of    long    bones,    pain    without 


56  INDICATIONS    FOR    OPERATION    IN 

tenderness  over  the  spine,  and  the  appearance  of  herpes 
zoster,    are   in   favour   of  tumour. 

Syphihs  must  be  considered,  and  will  be  indicated  by 
the  presence  of  other  lesions  elsewhere,  and  by  improvement 
under   antisyphilitic   treatment. 

With  regard  to  whether  a  growth  is  within  the  canal, 
or  growing  from  the  bone,  it  should  be  noted  that  metas- 
tatic growths  almost  always  arise  in  the  bone ;  and  hydatids 
are,  with  few  exceptions,  within  the  canal.  Osseous 
growths  usually  cause  greater  local  destruction  than 
tumours  of  the  canal  ;  deviation  of  the  spinous  processes 
points  to  a  bone  tumour.  An  exact  diagnosis  between 
vertebral  and  intravertebral,  and  between  extra-  and  intra- 
medullary tumours  cannot  be  made  with  certainty. 

INDICATIONS   FOR   OPERATION. 

When  the  symptoms  point  to  the  presence  of  a  single, 
primary,  intravertebral,  and  extramedullary  tumour,  and 
enable  one  to  make  an  exact  diagnosis  of  the  level  at  which 
it  is  situated,  then  an  operation  for  its  removal  should  be 
undertaken.  Operation  should  only  be  recommended  for 
a  metastatic  growth  when  the  primar}^  tumour  has  been 
removed,  and  when  there  is  reason  to  believe  that  no  other 
metastases  exist. 

Contra-indications. — The  operation  must  be  looked  upon 
as  a  serious  one,  and  should,  therefore,  not  be  undertaken 
unless  the  general  condition  is  good.  When  there  is  reason 
to  believe  that  the  tumour  is  intramedullary,  no  operation 
should  be  done,  in  particular  when  there  is  bilateral  partial 
anaesthesia  of  long  standing  with  extensive  and  rapidly 
progressive  muscular  atrophy,  paresis  of  both  legs,  and 
marked  involvement  of  the  upper  limbs.  Operation  is, 
likewise,  contra-indicated  for  metastatic  vertebral  tumours 
and  multiple  tumours,  and  should  never  be  undertaken  in 
any  case  until  antisyphilitic  treatment  has  been  tried. 

The  dangers  of  the  operation  are  still  great  ;  about  a  half 
of  the  cases  have  died,  either  immediately  or  some  days 
after  intervention. 

Prognosis. — Of  operation. — When  a  growth  is  successfully 
removed  recovery  may  follow,  providing  no  irreparable 
damage  has  been  done  to  the  cord.  Up  to  the  present, 
however,  the  number  of  successful  cases  is  small. 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     57 

The  results  of  an  error  in  diagnosis  may  be  disastrous  ; 
for  the  opening  of  the  vertebral  canal  is  always  dangerous, 
owing  to  the  risks  of  haemorrhage  and  infection. 

Prognosis  without  operation. — Tumour  of  the  spine  is 
necessarily  fatal  when  left  alone,  but  death  may  be  long 
postponed.  My  own  statistics  show,  in  sixty-three  cases  of 
intradural  growths,  an  average  duration  of  life  of  25"6 
months  from  the  appearance  of  the  first  symptoms  up  to 
death  ;  in  forty-six  extradural  cases  the  average  was  13"  6 
months.  In  these  statistics  I  have  not  included  the  very 
prolonged  cases,  sometimes  surviving  ten  years.  If  these 
were  included  the  figure  for  extradural  cases  would  rise  to 
17-2  months.  In  one  of  my  cases  death  did  not  occur  until 
four  years  after  the  time  when  operation  was  recommended  ; 
the  autopsy  showed  that  it  would  have  been  useless. 

LITERATURE. 

Bruns.     Die    Geschwiilste    des    Nervensystems.     Berlin.      1897. 

H.  ScHLESiNGER.  Beitr.  z.  Klinik  der  Riickenmarks  und  Wirbel- 
tumoren.     Jena:   G.  Fischer.      1898. 

Oppenheim.  Lehrbuch  d.  Nervenkrankheiten.  3rd  Ed.  Berlin. 
1902. 

F.  Krause.  Zur  Segmentdiagnose  der  Riickenmarksge- 
schwiilste.     Berl.  klin.  Wochens.     Nos.   20-22.      1901. 

L.  Bruns.  Die  Segmentdiagnose  der  Riickenmarkserkrank- 
ungen.     Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  iv. 

Henschen  und  Lenander.  Riickenmarkstumor.  Mitteil.  a.  d. 
Grenzgebiete  d.  Med.  u.  Chir.     Bd.  x. 

PuLMANN  and  Warren.  The  Surgical  Treatment  of  Tumours 
within  the  Spinal  Canal.     Amer.  Jour,  of  Med.  Sci.     October,  1899. 


ACUTE  POLIOMYELITIS. 

Etiology. — Poliomyelitis  is  probably  the  result  of  an 
infection.  Trauma,  perhaps,  plays  a  part  in  its  etiology, 
but  there  is  at  present  no  real  proof  of  this. 

Pathological  Anatomy. — ^Poliomyelitis  is  an  acute 
inflammatory  condition  of  the  anterior  horns  of  the  grey 
m^itter  of  the  cord.  The  meninges  and  the  grey  matter  of 
the  medulla  oblongata  may  participate  in  the  process. 

Clinical  Course. — The  disease  begins  acutely ;  the 
initial  symptoms  being  those  of  a  general  febrile  disorder. 
After  some  hours,  or  days,  paralysis  appears,  and  at  once 
attains  to  the  maximum  of  its  extent.     In  the  great  majority 


58  INDICATIONS    FOR    OPERATION    IN 

of  cases  this  paralysis  affects  one  or  both  of  the  lower  limbs  ; 
more  rarely  the  arms  or  the  four  extremities.  In  the  course 
of  a  week,  or  a  month,  the  extent  of  the  paralysis  often 
diminishes  ;  according  to  Remak  this  improvement  may 
take  place  even  after  the  lapse  of  a  year.  Increase  of  the 
paralysis  by  successive  aggravations  is  very  rare.  The 
paralysis  is  flaccid  and  degenerative,  and  after  the  early 
improvement  has  passed,  it  persists  in  several  muscles,  or 
muscle  groups.  Certain  muscles,  the  sartorius  for  example, 
are  very  rarely  paralyzed,  while  others  are  involved  in  a 
large  number  of  cases.  In  the  upper  limb  the  deltoid 
and  other  shoulder  muscles  are  exceptionally  often  affected. 
If  faradic  excitability  is  not  lost  in  a  paralyzed  muscle, 
functional  power  will  return  to  it.  Vasomotor  paralysis  in 
the  paralyzed  limbs  is  shown  by  the  bluish-red  colour  of 
the  skin.  The  sensory  functions,  and  those  of  the  bladder 
and  rectum,  are  undisturbed.  As  time  goes  on  it  is  noticed 
that  the  paralyzed  limb  is  shorter  than  its  fellow,  and  the 
bones  themselves  are  atrophied.  In  a  few  instances 
lengthening  has  been  recorded.  Deformities  are  produced 
by  contracture  of  the  antagonistic  muscle  groups.  For 
example,  if  the  tibialis  anticus  is  paralyzed,  and  the  peroneal 
muscles  unaffected,  pes  valgus  develops.  In  an  analogous 
way  pes  varus,  planus,  or  calcaneus  may  be  produced. 
Pes  equino-varus  occurs  when  the  extensor  muscles  are 
generally  affected,  with  the  exception  of  the  tibialis  anticus ; 
pes  planus  when  the  peronei  and  the  flexors  of  the  sole  are 
paralyzed;  and  pes  equinus  in  paralysis  of  the  calf  muscles. 
Contracture  of  the  flexors  of  the  knee  is  comparatively 
frequent.  Well-marked  contractures  of  the  upper  limb 
muscles  are,  on  the  other  hand,  very  uncommon.  When 
the  muscles  which  control  a  joint  are  paralyzed  the  joint 
becomes  flail  ;  this  is  especially  common  in  the  shoulder 
and  hip,  and  may  be  followed  by  spontaneous  luxation. 

Differential  diagnosis. — When  the  affection  has  been 
present  for  some  weeks  a  mistake  in  diagnosis  can  hardly 
occur.  Multiple  neuritis  progressively  increases  in  severity 
from  its  commencement  for  several  weeks ;  acute  polio- 
myelitis reaches  its  maximum  in  the  first  few  days.  In 
multiple  neuritis  the  fever  lasts  longer  ;  there  is  pain  and 
tenderness  on  pressure  in  the  nerves  and  muscles,  and 
there    are    disturbances    of    sensation,    which    are    almost 


DISEASES  OF  THE  SPINAL  COLUMN  AND  CORD.     59 

entirely  absent  in  poliomyelitis.  The  appearance  of  oedema 
and  the  participation  of  the  cranial  nerves  point  to  multiple 
neuritis  (Oppenheim). 

Injuries  to  the  spinal  cord  may  cause  symptoms  resembling 
those  of  poliomyelitis,  but  the  history  will  make  the 
diagnosis  clear.  Syringomyelia  develops  slowly  and  pro- 
gressively, and  evokes  certain  sensory  disturbances. 
Obstetric  paralysis  involves  the  upper  limbs  only  in  the 
areas  supplied  by  the  fifth  and  sixth  cervical  nerves. 

INDICATIONS   FOR   OPERATION. 

Only  the  effects  of  the  disease  can  be  dealt  with  by 
surgical  measures.  These  measures  may  be  divided  into 
three  groups,  (i)  Those  undertaken  to  relieve  the 
paralyses  of  some  parts  of  the  limbs  ;  (2)  Those  by  which 
contractures  are  overcome  to  render  possible  the  wearing 
of  some  orthopaedic  apparatus  ;  (3)  The  fixation  of  useless 
articulations.  For  the  relief  of  paralyses  the  grafting  of 
tendons  of  intact  muscles  on  to  those  of  paralyzed  muscles 
is  employed.  This  method  is  suitable  for  cases  of  partial 
paralysis  of  more  than  a  year's  standing  when  healthy 
vigorous  muscles  are  available  adjoining  the  paralyzed 
muscles. 

When  deformity  has  been  produced  by  contractures, 
tenotomy  is  to  be  employed  to  mobilize  the  affected  joints, 
in  particular  with  a  view  to  the  further  employment  of 
orthopaedic  apparatus. 

The  fixation  of  a  joint  (arthrodesis)  is  indicated  (i)  In 
total  paralysis  of  all  the  muscles  controlling  the  joint. 
(2)  Where  without  total  paralysis  the  joint  is  nevertheless 
flail.  (3)  In  complete  functional  uselessness  of  a  joint 
owing  to  secondary  contractures.  By  arthrodesis  the 
necessity  for  the  wearing  of  special  orthopaedic  apparatus 
is  avoided,  and  it  is,  therefore,  of  value  when  the  cost  of 
such  apparatus  cannot  be  borne,  or  the  time  necessary  for 
carrying  out  orthopaedic  treatment  is  not  available. 

In  writing  of  the  value  of  arthrodesis  for  poliomyelitic 
paralysis  at  the  shoulder,  Vulpius  recommends  that  it  should 
be  practised  only  when  there  is  no  prospect  of  further 
spontaneous  improvement,  that  is  to  say,  when  the  paralysis 
has  been  present  for  over  a  year,  and  only  when  the  hand 
is  unaffected  ;    its  usefulness   is  somewhat  prejudiced  by 


6o  INDICATIONS    FOR    OPERATION. 

paralysis  of  the  upper  arm  muscles,  yet  it  may  be  properly 
recommended  under  such  circumstances. 

Results  of  operation. — Tendon  transplantation  often 
restores  the  function  of  a  limb  to  a  notable  degree  ;  the 
results  reported  by  Vulpius  illustrate  this  in  a  remarkable 
manner.  The  fixation  of  joints  often  greatly  increases  the 
usefulness  of  a  limb,  and  facilitates  the  application  of 
further  orthopaedic  treatment. 

The  risks  of  operation  are  inconsiderable. 

LITERATURE. 

HoFFA.     Orthopadische  Chirurgie.      3rd  Ed. 
Oppenheim.     Lehrbuch  d.  Xervenkrankhheiten.     31-d.  Ed. 
Vulpius.     Zur  Sehneniiberpflanzung.   Deut.   Zeitscli.   f.   Nerven- 
heilkunde.     Bd.  xxii. 

Vulpius.     Die  Sehneniiberpflanzung.     Leipzig,  1902:   Veil  &  Co. 


CHAPTER     III. 

Diseases   of  the    Peripheral    Nerves. 


63 


Chapter  III. 
DISEASES  OF  THE  PERIPHERAL  NERVES. 

NEURALGIA     OF     THE     FIFTH     CRANIAL     NERYE 

{Tic    Doloureux). 

Etiology. — Trigeminal  neuralgia  may  be  due  to  a 
variety  of  causes.  It  may  be  associated  with  one  of  the 
infective  diseases,  such  as  malaria  and  influenza,  or  follow 
chill  or  trauma.  It  may  be  set  up  by  disease  in  some 
neighbouring  structure,  bone,  meninges,  vessels,  or  be  due 
to  caries  of  the  teeth,  anaemia,  affections  of  the  digestive 
tract,  or  disorders  of  the  female  genital  organs. 

Clinical  Course. — The  affection  is  characterized  by 
attacks  of  intense  pain,  often  apparently  brought  on  by  some 
slight  extraneous  cause,  or  occurring  spontaneously. 

The  attack  is  often  accompanied  by  watering  of  the 
eyes,  by  profuse  discharge  from  the  nose,  or  by  excessive 
salivation,  according  as  the  neuralgia  particularly  affects 
the  first,  second,  or  third  branches  of  the  nerve.  The 
skin  of  the  face  and  the  conjunctiva  are  usually  injected, 
and  a  herpetic  eruption  sometimes  appears  on  the  nose 
or  the  face.  Pressure  on  the  points  of  exit  of  the  branches 
is  often  very  painful.  Occasionally,  but  very  rarely, 
there  is  partial  anaesthesia  of  the  area  supplied  by  the 
nerve.  The  pain  radiates  from  the  branch  first  affected 
to  others,  and  sometimes  to  the  occipital  and  cervical 
nerves. 

Diagnosis  and  Differential  Diagnosis. — The  diagnosis 
is  based  on  the  clinical  symptoms  already  noted.  The 
condition  must  be  differentiated  from  frontal  and  maxillary 
sinusitis,  which  usually  follow  influenza,  are  characterized 
by  purulent  secretion  from  the  nose,  and  may  be  demon- 
strated by  transillumination.  It  may  be  distinguished 
from    frontal   periostitis,    particularly   the   syphilitic   form, 


64  INDICATIONS    FOR    OPERATION    IN 

by  the  local  signs  revealed  by  palpation,  and  by  the  results 
of  antisyphilitic  treatment.  Dental  neuralgia  will  be 
indicated  by  the  presence  of  carious  teeth  tender  to  pressure. 
Glaucoma  is  differentiated  from  neuralgia  of  the  ciliary 
branches  by  the  increase  of  ocular  tension,  restriction  of 
the  visual  field,  and  by  the  appearances  seen  with  the 
ophthalmoscope.  In  migraine  there  is  intense  pain,  but, 
in  addition,  photophobia,  auditory  hypercesthesia,  a 
tendency  to  vomiting,  and  relatively  severe  general  disturb- 
ance. Cephalalgia  is  usually  bilateral,  and  is  different  in 
localization  from  trigeminal  neuralgia.  In  rheumatism 
of  the  scalp  the  latter  is  diffusely  tender  to  pressure.  When 
trigeminal  neuralgia  is  due  to  some  central  cause  there 
will  be  present  other  symptoms  referable  to  involvement 
of  other  cranial  nerves. 

INDICATIONS   FOR   OPERATION. 

Operation  is  only  called  for  when  the  diagnosis  of  severe 
peripheral  trigeminal  neuralgia  is  clearly  established,  and 
when  the  various  internal  and  external  remedies  which 
are  recommended  for  the  condition  have  proved  ineffectual. 
It  is  to  be  looked  upon  as  a  last  resource  when  the  pain  is 
unbearable  and  other  means  have  failed.  If  the  neuralgia 
is  confined  to  one  branch,  one  of  the  procedures  of  lesser 
severity  should  be  employed.  If  these  fail,  and  only  after 
they  have  been  tried,  should  removal  of  the  Gasserian 
ganglion,  or  section  of  the  nerve  behind  the  ganglion,  be 
undertaken. 

Contra-indications. — In  bilateral  neuralgia  operation  will 
probably  be  unsuccessful  (Friedrich),  and  is  not  to  be 
recommended.  If  after  careful  resection  of  a  portion  of 
a  nerve,  symptoms  return  in  the  corresponding  area  of 
innervation,  either  immediately  or  after  a  short  period, 
then  a  further  operation  will  probably  be  attended  with 
little  success.  When  it  appears  probable  that  the  neuralgia 
is  due  to  some  central  lesion  no  operation  on  the  nerve  is 
justifiable. 

Prognosis. — Of  operation. — Of  Thiersch's  cases,  kept 
under  observation  for  six  years,  more  than  a  third  remained 
entirely  free  from  recurrence,  while  in  about  a  third  there 
was  a  definite  return  of  symptoms.  These  were  all  cases 
of  severe  trigeminal  neuralgia  of  several  years'  standing, 


DISEASES    OF    THE    PERIPHERAL    NERVES.         65 

and  were  treated  by  nerve  resection.  Extirpation  of  the 
Gasserian  ganglion  appears  to  afford  permanent  relief ; 
there  was  no  return  of  symptoms  in  any  of  Krause's  cases. 

Risks  of  operation. — Krause's  operation  is  attended 
with  delinite  risk.  In  about  15  per  cent  (17  out  of  113 
cases)  death  has  followed  the  operation.  It  is  remarkable 
that  neuroparalytic  keratitis,  or  other  serious  complication, 
has  rarely  occurred. 

Nerve  resection  is,  of  course,  a  much  less  serious  opera- 
tion, and,  unless  complications  occur,  is  unattended  by 
risk  to  life. 

LITERATURE. 

Krause.  Die  Neuralgic  des  Trigeminus.  Leipzig,  1896.  Also 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ii. 

Friedrich.  Zur  chirurg.  Behandlung  der  Gesichtsneuralgie 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.       Bd.  iii. 

Bernhardt.  Krankheiten  der  peripheren  Nerven.  Nothnagel's 
Handbuch  der  spez.  Pathol.       Bd.  xi.     Wien. 

Thiersch.    Verhandlung  d.  deutschen  Gesellsch.  f.  Chirurg.     1889. 


OCCIPITAL  NEURALGIA. 

Clinical  Signs. — Occipital  neuralgia  is  a  term  used  to 
indicate  neuralgia  of  the  sensory  branches  of  the  cervical 
plexus.  Usually  the  pain  extends  from  the  neck  to  the 
vertex  in  the  distribution  of  the  great  occipital.  More 
rarely  it  is  situated  laterally  in  the  distribution  of  the 
small  occipital  and  great  auricular.  The  pain  is  paroxysmal, 
and  more  frequently  complained  of  in  the  evening  than 
the  morning.  During  the  attack  the  head  is  kept  rigid 
and  the  occiput  supported  with  the  hand,  the  skin  over 
the  occiput  being  often  tender  to  pressure.  Three  tender 
points  may  be  demonstrated :  the  occipital  point  between 
the  mastoid  process  and  the  atlas,  the  parietal  point  in  the 
neighbourhood  of  the  parietal  eminence,  and  the  cervical 
point  between  the  anterior  border  of  the  trapezius  and 
the  posterior  border  of  the  sternomastoid. 

Etiology.  —  Most  frequently  this  affection  follows 
exposure  to  cold  or  trauma,  or  in  the  course  of  some  infectious 
disease,  or  some  intoxication.  Hysteria  and  neurasthenia 
may  also  influence  its  onset.  Frequently  it  arises  in 
connection  with  disease   of  the  vertebrae  or  the   meninges 

S 


66  INDICA  TIONS    FOR    OPERA  TION    IN 

(tuberculosis,  carcinoma,  syphilis,  arthritis  deformans). 
Sometimes  it  is  due  to  tumour  of  the  brain  or  other 
central  lesion. 

Diagnosis  and  Differential  Diagnosis. — In  diagnosis 
special  attention  should  be  paid  to  the  tender  points  and 
to  the  absence  of  other  phenomena.  The  posterior 
pharyngeal  wall  will  be  examined  for  signs  of  vertebral 
disease.  In  rheumatism  of  the  neck  muscles  the  affected 
muscles  are  tender  to  pressure.  Hysterical  pain  in  the  neck 
is  influenced  by  suggestion,  and  usually  extends  to  the 
back  ;  the  tender  spots  do  not  correspond  to  the  points  of 
emergence  of  the  great  occipital.  In  cervical  Pott's  disease 
there  are  spinal  symptoms,  persistent  rigidity  of  the  vertebral 
column,  and  swelling  of  the  overlying  soft  parts. 

INDICATIONS   FOR   OPERATION. 

Operation  may  be  advised  when  all  medical  remedies  have 
proved  ineffectual.  This  will  consist  of  division  of  the 
nerve  near  its  proximal  end,  and  exeresis  of  the  peripheral 
branches  by  the  method  of  Thiersch.  If  intense  pain 
persists  in  spite  of  this,  the  more  serious  operation  of  division 
of  the  posterior  roots  of  the  upper  cervical  nerves  in  the 
spinal  canal  is  indicated  (Chipault),  but  this  should  at 
present  be  reserved  for  what  may  be  called  the  desperate 
cases. 

Prognosis. — Risks  of  operation. — The  risk  of  cutting  or 
injuring  the  phrenic  nerve  is  small  if  Krause's  procedure  be 
followed.  The  division  of  the  posterior  roots  is  a  distinctly 
dangerous  operation. 

Contra-indications  to  operation. — If  some  disease  of  the 
vertebrae  is  present,  if  there  is  some  central  lesion,  or  if 
the  neuralgia  is  due  to  functional  causes,  no  operation 
should  be  done  on  the  nerves  or  roots. 

LITERATURE. 

Bernhardt.  Krankheiten  der  peripheren  Nerven,  ii.  Noth- 
nagel's  Handbuch  d.  spc.  Pathol.     Bd.  xi.     Wien. 

Chipault  et  Demoulin.  La  Resection  Intradurale  des  Racines 
Medullaires.     Nouv.  Iconograph.  de  la  Salpetriere.     No.  95,    1895. 

Krause.  Die  operative  Behandlung  der  schweren  Occipital- 
neuralgic.     Beitr.  z.  klin.  Chir.     Bd.  xxiv. 


DISEASES    OF    THE    PERIPHERAL    NERVES.         67 

BRACHIAL    NEURALGIA. 

Etiology. — According  to  Oppenheim  some  neuropathic 
predisposition  is  usually  present  in  cases  of  brachial 
neuralgia.  The  infective  disorders,  anaemic  and  cachectic 
states,  diabetes,  and  gout  also  predispose  to  the  affection. 

Many  cases  are  due  to  trauma,  such  as  wounds  or  fractures 
of  the  upper  arm  and  clavicle  ;  others  are  due  to  affections 
of  the  subclavian  artery  or  aorta,  or  to  the  presence  of  a 
cervical  rib. 

Pathological  Anatomy. — Brachial  neuralgia  may  be 
caused  by  gross  anatomical  lesions  in  the  neighbourhood 
of  the  nerves,  but  under  such  circumstances  neuritis,  more 
commonly  than  neuralgia,  results.  Such  gross  lesions  may 
be  the  result  of  the  pressure  of  a  cervical  rib  (especially  if 
affected  with  periostitis),  the  pressure  of  callus  or  scar 
tissue,  of  a  bone  splinter,  or  a  foreign  body.  In  torticollis 
the  contractured  neck  muscles  may  exert  direct  pressure 
on  the  nerves  of  the  brachial  plexus. 

Clinical  Signs. — Generally,  in  brachial  neuralgia,  the 
distribution  of  the  pain  is  not  sharply  defined,  but  it  may 
chiefly  affect  the  distribution  of  a  single  nerve.  The  pain 
is  sometimes  continuous,  more  frequently  paroxysmal,  and 
easily  set  up  by  movements  of  the  arm.  Painful  spots  are 
found  at  the  point  where  the  radial  nerve  passes  to  the 
dorsum,  over  the  ulnar  nerve  by  the  side  of  the  olecranon, 
over  the  median  in  the  fold  of  the  elbow,  over  the  joints  of 
the  hand,  and  over  the  plexus  itself,  to  the  side  of  the 
lowest  cervical  vertebrae.  Trophic  disturbances  develop  only 
when  neuritis  is  present. 

Diagnosis  and  Differential  Diagnosis. — In  many 
affections  of  the  central  nervous  system  pain  may  be  present 
in  the  distribution  of  the  brachial  plexus,  for  example  in 
tabes,  syringomyelia,  tumour  of  the  cord,  pachymeningitis, 
and  spondylitis  ;  but  these  are  differentiated  by  the  presence 
of  other  characteristic  symptoms,  and  the  same  is  true  of 
diseases  of  the  large  vessels.  The  diagnosis  is  only  arrived 
at  after  excluding  diseases  of  the  bones,  joints,  and  muscles. 

INDICATIONS   FOR  OPERATION. 

The  indications  may  be  divided  into  two  classes.  If  the 
signs  point  to  compression  of  nerves  by  callus  or  other  means, 


68  INDICATIONS    FOR    OPERATION    IN 

or  to  complete  or  partial  severance  of  nerves,  these  lesions 
should  be  dealt  with  by  operation  as  soon  as  possible. 
Cervical  ribs  should  be  removed,  if  no  other  cause  for  the 
neuralgia  is  to  be  found  ;  in  two  such  cases  under  my  care, 
removal  of  the  rib  was  followed  by  complete  disappearance 
of  the  pain.  If  torticollis  is  complicated  by  constant 
bronchial  neuralgia,  the  sternomastoid  should  be  divided. 

When  no  gross  anatomical  lesion  can  be  discovered  to 
account  for  the  neuralgia,  operation,  that  is  to  say,  stretching 
of  the  nerve,  either  after  open  operation  or  by  the  bloodless 
method  of  Naegeli,  should  only  be  practised  when  all  other 
methods  of  treatment  have  failed. 

Contra-indications. — No  proposal  to  operate  will  be 
entertained  if  the  neuralgia  is  caused  by  some  inaccessible 
anatomical  lesion. 

All  symptomatic  neuralgias,  such  as  those  secondary 
to  diseases  of  the  spinal  cord  and  vertebrae  (except  tumours 
of  the  nerve  roots  and  meninges),  or  to  affections  of  the 
large  vessels,  are  also  unsuitable  for  operation. 

When  no  operation  is  undertaken  the  lesion  which  is 
setting  up  the  neuralgia  will,  in  many  cases,  give  rise  to 
destructive  anatomical  changes  in  the  nerve,  and  the 
resulting  damage  may  be  irreparable. 

LITERATURE. 

Befnhardt.  Krankheiten  der  peripheren  Nerven,  Th.  ii. 
Nothnagel's  Handbuch  d.  spez.  Pathol.     Bd.  xi.     Wien. 

Bernhardt.  Ueber  Halsrippen.  Berl.  klin.  Wochens,  1895. 
No.  4. 

Oppenheim.     Lehrbuch  d.  Nervenkrankheiten.     3rd  Ed.      1902. 

H.  Weiss.  Die  Halsrippen  und  ihre  klin.  Erscheinungen.  Zentralb. 
f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1900. 

Kader.  Neuralgic  des  Plexus  Cervicalis  und  Brachialis.  jMitteil. 
a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ii. 

Naegeli.  Therapie  v.  Neuralgien  durch  Handgriffe.  2nd  Ed. 
Jena.     1899.     G.  Fischer. 

INTERCOSTAL  NEURALGIA. 

Etiology. — Intercostal  neuralgia  is  especially  common 
in  anaemic  individuals,  in  pulmonary  tuberculosis,  and  after 
influenza.  Among  other  etiological  factors  must  be  men- 
tioned hysteria,  debility  after  fevers  and  during  lactation, 
and  some  affections  of  the  circulatory  system. 


DISEASES    OF    THE    PERIPHERAL    NERVES.         69 

Clinical  Signs. — The  pain  is  usually  in  the  distribution 
of  the  anterior  branches  of  several  of  the  intercostal  nerves  ; 
it  is  sometimes  very  intense  and  increased  by  movements, 
such  as  coughing  and  sneezing.  There  are  usually  three 
tender  spots ;  one  close  to  the  vertebra — the  vertebral  point ; 
one  in  the  axillary  line — the  lateral  point ;  and  one  near  the 
middle  line  in  front.  The  skin  of  the  affected  area  is  usually 
hypertesthetic.  The  affection  is  more  common  on  the  left 
than  on  the  right  side  of  the  body. 

Diagnosis  and  Differential  Diagnosis. — Intercostal 
neuralgia  is  very  often  a  symptom  of  disease  elsewhere.  It 
may  be  produced  by  disease  (tuberculosis  or  tumour)  of  the 
vertebrcE,  of  the  meninges  (meningitis,  tumour),  or  of  a 
spinous  process.  It  is  frequently  a  symptom  of  the  neuritis 
of  herpes  zoster  ;  it  may  also  be  associated  with  injuries 
to  the  ribs,  or  with  aortic  aneurysm.  Such  conditions  will 
be  recognized  by  other  characteristic  signs.  The  presence 
of  anaesthesia  is  against  a  simple  neuralgia,  as  is  also  the 
presence  of  vertebral  deformities,  severe  cord  symptoms, 
or  of  abnormalities  of  the  ribs.  The  diagnosis  will  be 
based  on  the  clinical  signs  already  related. 

INDICATIONS   FOR  OPERATION. 

Most  intercostal  neuralgias  improve  spontaneously,  or 
after  internal  medication,  so  that  only  the  subacute  and 
chronic  forms  are  suitable  for  operation  if,  after  other 
methods  of  treatment  have  been  tried,  the  pain  still  persists 
in  an  intense  form,  and  is  not  merely  symptomatic  of 
disease  elsewhere.  Operation  will  take  the  form  either 
of  stretching,  resection  of  the  nerve,  or  division  of  the 
posterior  root  within  the  dura  mater. 

Contra-indications. — Operation  will  not  be  undertaken 
when  lesions,  such  as  aneurysm,  spinal  disease,  etc.,  are 
present.  According  to  our  present  knowledge  of  herpes 
zoster,  operation  is  not  justifiable  for  the  associated 
neuralgia. 

Prognosis. — Risks  of  operation. — The  resection  of 
one  or  more  nerves  is  not  attended  by  any  risk,  but  the 
results  have  been  favourable  only  in  a  certain  number  of 
cases.  Nerve  stretching  may  also  fail  to  relieve.  Division 
of  the  posterior  roots  is  an  operation  dangerous  to  life,  and 
recovery  from  the  neuralgia,  cannot  be  guaranteed. 


70  INDICATIONS    FOR    OPERATION    IN 

LITERATURE.      - 

Oppenheim.     Lehrbuch  d.  Nervenkrankheiten.     3rd  Ed.     p.  523. 

Bern.^ardt.  Krankheiten  der  peripheren  Nerven.  Nothnagel'S 
Handbuch  d.  spez.  Pathol.     Bd.  ix.,  2  Halfte,  p.  318. 

ScHEDE.  Handbuch  d.  spez.  Therap.  von  Penzold-Stintzingj 
2nd  Ed. 


MERALGIA  PARAESTHETICA   (Roth-Bernhardt). 

[Neuralgia   of  the  Nervus    Cutaneus   Femoris    Externus.) 

Etiology. — This  affection  often  develops  after  exposure 
to  cold,  injury,  acquired  syphilis,  infectious  diseases,  gout, 
and  pregnancy.  It  occurs  with  especial  frequency  in 
alcoholics,  more  rarely  in  affections  of  the  central  nervous 
system. 

Pathological  Anatomy.  —  Often  some  anatomical 
peculiarity  can  be  demonstrated  causing  pressure  on  the 
nerve,  and  in  particular  pressure  by  the  iliofemoral  band, 
with  which  the  nerve  is  in  close  association  for  a  considerable 
part  of  its  course.  In  one  case  pressure  by  the  sharp  edge 
of  the  iliopectineal  ligament  was  found  to  be  the  cause 
of  the  pain.  Examination  of  resected  portions  of  the 
nerve  has  demonstrated  various  anatomical  changes 
(neuritis,  etc.). 

Clinical  Signs. — The  characteristic  of  this  condition  is 
the  presence  of  defined  areas  of  sensory  disturbance, 
subjective  and  objective,  over  the  outer  side  of  the  thigh 
below  the  trochanter,  all  the  sensory  functions  being  equally 
affected.  Occasionally  the  front  of  the  thigh  is  affected. 
The  pains  are  usually  worse  when  the  patient  is  standing, 
and  relieved  when  he  lies  down  ;  they  are  often  bilateral. 
The  symptoms  may  persist  for  many  years. 

INDICATIONS   FOR   OPERATION. 

Operation  is  only  indicated  when  other  treatment,  local 
and  general,  has  failed,  and  when  the  affection  is  present 
in  an  acute  form.  Such  operation  will  consist  of  stretching 
or  resection  of  the  nerve,  or  freeing  of  the  ligament  which 
is  compressing  the  nerve.  Operation  should  be  recom- 
mended early,  if  the  patient  is  prevented  from  following 
his    usual    occupation.      When     some     central    lesion    is 


DISEASES    OF    THE    PERIPHERAL    NERVES.         71 

associated  with  the  symptoms   of  meralgia,  no  operation 
should  be  done  on  the  nerve. 

Results. — When  the  nerve  is  resected  there  will  remain 
anaesthesia  over  the  area  of  its  distribution.  As  a  rule, 
operation  relieves  the  symptoms  entirely  ;  if  there  be  any 
return  it  is  usually  of  a  mild  type. 

LITERATURE. 

Bernhardt.  Krankheiten  der  peripheren  Nerven.  Nothnaj2;ers 
Handbuch  d.  spez.  Pathol.     Wien.      1895. 

Roth.     Meralgia  Paraesthetica.     Berlin:     Karger.      1895. 

Brisard.     Meralgia  Paraesthetica.     These  de  Paris.      1900. 

H.  ScHLESiNGER.  Die  Meralgia  Paraesthetica.  Zentralb.  f.  d. 
Grenzgebiete  d.  Med.  u.  Chir.      1900. 

Neisser  und  Pollack.  Beitr.  z.  Kenntniss  der  Roth-Bernhardt's 
Meralgia.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.  Bd.  x.  H.  3 
and  4. 


SCIATICA. 

Etiology. — Exposure  to  cold,  or  injury,  is  frequently 
concerned  in  the  etiology  of  sciatica ;  also  gout,  diabetes 
mellitus,  and  certain  intoxications — alcohol,  lead.  It  may 
also  be  set  up  by  venous  engorgement  in  the  pelvis,  com- 
pression by  tumours,  by  the  gravid  uterus,  or  by  fsecal 
masses,  and  by  certain  infective  disorders — gonorrhoea, 
syphilis,  enteric  fever,  influenza,  etc. 

Anatomical  Changes. — The  nerve  is  in  many  cases 
fixed  to  surrounding  parts  by  adhesions,  in  others  com- 
pressed by  changes  in  neighbouring  organs.  Pure  sciatic 
neuralgia  is  not  accompanied  by  inflammatory  changes  in 
the  nerve. 

Clinical  Signs. — By  sciatica  is  meant  a  neuralgia  of 
the  great  sciatic  nerve  and  its  branches.  Pain  is  usually 
complained  of  along  the  whole  length  of  the  nerve  from 
the  buttock  to  the  toes,  is  increased  by  pressure,  and  by 
movement,  and  comes  and  goes  in  attacks  of  considerable 
violence.  There  is  frequently  some  scoliosis,  with  the 
concavity  of  the  curve  on  the  affected  side.  There  are, 
as  a  rule,  tender  spots  along  the  nerve,  for  example  between 
the  trochanter  and  the  tuber  ischii.  Acute  pain  is  caused 
if  the  thigh  is  flexed  with  the  knee  extended.  There  is 
no  motor  paralysis,  and,  as  a  rule,  no  objective  sensory 


72  INDICATIONS    FOR    OPERATION    IN 

disturbance.     Occasionally  cold  spots  may  be  demonstrated 
on  the  skin  of  the  leg. 

Diagnosis  and  Differential  Diagnosis. — The  clinical 
signs  just  mentioned  will  make  the  diagnosis  clear. 
Marked  sensory  disturbances  co-existing  with  degenerative 
atrophy  point  to  neuritis.  Many  affections  give  rise  to 
pain  in  the  area  of  the  great  sciatic,  and  simulate  true 
sciatica.  In  lumbago,  the  tender  spots  along  the  nerve 
are  absent  ;  in  affections  of  the  cord,  and  in  tubercular 
and  carcinomatous  spondylitis,  there  are  various  spinal 
symptoms  which  are  absent  in  true  sciatica  :  weakness 
of  the  legs,  changes  in  the  tendon  reflexes,  disturbances 
of  the  bladder  and  rectum.  Certain  vascular  affections, 
arteriosclerosis  and  endarteritis  obliterans,  may  cause  pain 
in  the  legs,  but  are  usually  associated  with  alterations  in 
the  pulse  of  the  arteries  of  the  foot.  Rectal  and  vaginal 
examination  will  enable  one  to  exclude  the  possibility  of 
pelvic  new  growths  involving  the  sciatic  nerve.  In  disease 
of  the  hip  joint  all  movement  at  the  joint  is  painful,  whether 
the  knee  is  extended  or  not. 

INDICATIONS   FOR   OPERATION. 

When  internal  treatment  has  failed  and  the  pain  is 
severe,  stretching  the  nerve  should  be  undertaken,  first  by 
the  bloodless  method  ;  and  then,  if  this  be  unsuccessful, 
by  open  operation.  If  sciatica  follows  a  definite  trauma, 
then  operation  should  be  advised  earlier  (stretching  of  the 
nerve  after  exposure  by  incision),  but  not  infrequently  the 
symptoms  are  unrelieved  thereby.  In  one  case  under  my 
own  observation  there  was  no  improvement  until  two 
years  after  stretching. 

Contra-indications. — Sciatic  pains  caused  by  inoperable 
tumours  of  the  pelvis  or  spinal  column,  or  secondary  to 
some  spinal  disease,  are  not  suitable  for  operation.  No 
operation  should  be  done  when  the  symptoms  are  due  to 
some  disorder  of  nutrition. 

Risks  of  the  operation. — Bloodless  stretching  appears 
to  be  free  from  risk.  After  the  open  operation,  motor  and 
sensory  paralysis,  both  temporary  and  persisting,  have 
been  observed  in  a  few  cases.  I  have  seen  a  case  of 
paralysis  persisting  five  years  after  operation. 


DISEASES    OF    THE     PERIPHERAL    NERVES.         73 

LITERATURE. 

Bernhardt.  Krankheiten  der  peripheren  Nerven.  Nothnagel's 
Handbuch  d.  spez.  Pathol.     Bd.  xi.     Wien. 

ScHEDE.  Chirurgie  der  peripheren  Nerven.  Handbuch  d.  spez. 
Therap.   von  Penzold-Stintzing.      2nd  Ed.     Bd.   v. 


FACIAL  SPASM. 

Etiology. — Among  the  causes  of  facial  spasm  are : 
affections  in  the  distribution  of  the  fifth  nerve  (teeth, 
cornea,  conjunctiva,  etc.),  direct  irritation  of  the  seventh 
nerve  by  tumour,  aneurysm,  or  other  mechanical  cause, 
psychical  disturbances  in  hysterical  and  neurasthenic 
individuals. 

Clinical  Signs. — The  spasm  is  more  frequently  clonic 
than  tonic  ;  it  is  sometimes  confined  to  one  or  two  muscles, 
but  usually  affects  the  whole  of  one  side  of  the  face. 
Generally  it  occurs  in  paroxysms,  and  is  provoked  by 
mastication,  speaking,  emotional  disturbance,  or  exposure 
to  cold.  In  some  cases,  particularly  in  blepharospasm, 
there  are  tender  spots  to  be  found  at  the  points  of  emergence 
of  the  trigeminal,  especially  the  supra-orbital  branch, 
and  pressure  on  these  points  may  temporarily  check  the 
muscular  spasm.  The  affection  is  usually  chronic,  and 
persists  for  many  years. 

INDICATIONS   FOR   OPERATION. 

Even  in  inveterate  cases,  which  have  resisted  other 
methods  of  treatment,  operation  should  only  be  undertaken 
after  it  has  been  explained  to  the  patient  that  success  is 
exceptional,  and  when  he  still  persists  in  his  desire  that  an 
attempt  should  be  made  to  relieve  him  by  these  means. 
There  cannot,  therefore,  be  said  to  be  any  absolute  indica- 
tion for  the  operation.  When  the  spasm  is  arrested  by 
compression  of  the  supra-orbital  nerve,  resection  of  the 
latter  (not  simple  division)  should  be  done,  and  has  given 
relief  in  many  cases.  When  the  spasm  is  not  checked  by 
pressure  on  any  such  point,  and  when  the  patient  persists 
in  his  demand  for,  at  any  rate,  a  temporary  relief,  even  at 
the  risk  of  paralysis,  the  nerve  may  be  stretched  after 
exposure  by  incision.  When  function  returns  to  the 
facial  muscles,  the  spasm  may  also  return.     If  this  operation 


74  INDICATIONS    FOR    OPERATION    IN 

is  unsuccessful  the  application  of  the  actual  cautery  to 
the  neck  may  be  tried,  but  the  indications  for  this  are  no 
more  definite  than  those  for  other  operative  measures  in 
this  affection. 

LITERATURE. 

Bernhardt.    Krankheiten  der  peripheren  Nerven.   Part  2.    Noth- 
nagel's  Handbuch  d.  spez.  Pathol.     Wien.      1898. 

GowERS.     Diseases  of  the  Nervous  System.     Vol.  ii. 

Oppenheim.     Lehrbuch  d.  Nervenkrankheiten.     3rd  Ed. 

Brissaud.     Lecons  sur  les  Maladies  Nerveuses.    Tome  i.,  p.  502 
Paris.      1895. 

ScHOTT.     Ueber   Facialisdehnung.    beim    Facialiskrampf.     Deut. 
med.  Wochens.     No.  44,  1891. 


SPASM  OF  CERVICAL  MUSCLES   (Spasmodic  Torticollis). 

Etiology. — This  affection  is  most  frequently  found  in 
individuals  of  neuropathic  tendencies.  It  may  be  set  up 
by  traumata,  intoxications,  and  organic  lesions  of  the  brain 
and  spine. 

Clinical  Signs. — The  spasm  may  be  clonic  or  tonic, 
unilateral  or  bilateral.  Sometimes  only  one  muscle  is 
affected,  sometimes  a  whole  muscle  group,  and  sometimes 
the  whole  of  the  muscles  of  the  neck.  The  sternomastoid 
and  trapezius  muscles  are  involved  with  special  frequency  ; 
sometimes  the  affected  muscles  show  hypertrophy.  The 
intensity  of  the  attacks  is  increased  by  emotional  dis- 
turbances ;  for  example,  if  the  patient  sees  that  he  is  being 
watched  the  spasm  will  be  exaggerated  ;  during  rest  and 
sleep  the  attacks  tend  to  pass  off. 

Differential  diagnosis. — In  chorea,  the  convulsive  move- 
ments are  distributed  more  or  less  generally  over  the 
body,  and  are  less  intense  ;  the  same  is  true  of  myoclonus. 
When  the  spasm  is  tonic,  rheumatic  torticollis  has  to  be 
excluded ;  in  the  latter  there  is  much  pain  in  the  neck, 
and  the  muscles  themselves  are  tender  to  pressure. 
Organic  lesions  of  the  cervical  spine  (tumour,  spondy- 
litis), may  give  rise  to  tonic  spasm  of  the  neck  muscles  ; 
but  the  other  symptoms  by  which  they  are  characterized 
enable  a  correct  diagnosis  to  be  made.  In  congenital 
torticollis  there  are  changes  in  the  cervical  spine  and 
shortening  of  the  muscles. 


DISEASES    OF    THE    PERIPHERAL    NERVES.         75 
INDICATIONS    FOR   OPERATION. 

Operation  will  only  be  undertaken  when  other  methods 
of  treatment  have  failed  :  when  the  patient  prefers  the 
chance  of  paralysis  of  the  neck  muscles  to  the  condition  of 
spasm  from  which  he  is  suffering,  and  of  the  appearance 
of  spasm  in  other  muscles  after  the  operation.  Section, 
stretching,  and  even  resection  of  the  spinal  accessory  nerve 
has  sometimes  proved  inefficient.  Tenotomy  of  one  or 
two  of  the  tendons  of  the  neck  muscles  is  usually 
unsuccessful,  but,  as  far  as  present  experience  goes,  more 
success  has  attended  the  operation  of  Kocher  and  Quervain, 
in  which  the  tendons  of  almost  all  the  muscles  of  the  neck 
are  cut.  This  operation  shows  the  greatest  average  number 
of  successes,  and  next  to  it  comes  resection  of  the  spinal 
accessory. 

Contra-indications. — Operation  will  probably  be  inad- 
visable in  cases  in  which  some  cerebral  or  spinal  process 
appears  to  be  the  cause  of  the  spasm,  or  in  which  some 
general  neurosis  is  present. 

Prognosis. — Risks  of  the  operation. — Other  neighbouring 
and  previously  unaffected  muscles  may  develop  the  spasm 
soon  after  the  operation,  and  the  latter  prove,  therefore, 
useless.  The  paratysis  which  follows  division  of  the  nerve 
is  often  slight,  and  does  not  incapacitate  the  patient  to 
any  considerable  extent. 

Without  operation  no  serious  consequences  are  to  be 
anticipated  ;  in  many  cases  treatment  without  operation 
is  successful  even  when  the  condition  has  been  present  for 
a  long  time. 

LITERATURE. 

Bernhardt.  Krankheiten  der  peripheren  Nerven.  Part  2. 
Nothnagel's   Handbuch   d.    spez.    Pathol      Bd.    xi.     Wien. 

Richardson  and  Walton.  The  Operative  Treatment  of  Spas- 
modic Torticollis.     Amer.  Jour.  Med.  Sci.     Jan.,  1895. 

Brissaud  Torticollis  Mental.  Lecons  sur  les  Maladies  Nerveuses. 
Tome  i.,  p.  504.     Paris.     1895. 

Smith.     Brit.  Med.  Jour.     April,  4,  1891. 

PERFORATING  ULCER  OF  THE  FOOT. 

Etiology. — This  condition  is  usually  due  to  some 
pathological  change  in  the  peripheral,  or  central  nervous 
system.     Among   the   most   frequent   of   these   are   tabes, 


76  INDICATIONS    FOR    OPERATION    IN 

syringomyelia,  general  paralysis,  spina  bifida,  traumatic 
affections  of  the  cord,  leprosy,  peripheral  neuritis  diabetic 
and  alcoholic. 

Clinical  Course. — Perforating  ulcer  of  the  foot  runs 
a  painless  and  chronic  course  ;  it  makes  its  way  steadily 
into  the  deeper  structures,  and  usually  resists  all  local 
treatment  ;  it  tends  to  recur  (Borchard-Nasse).  In  the 
neighbourhood  of  the  ulcer,  or  over  the  whole  foot,  there  is 
usually  some  anaesthesia,  and  certain  trophic  disturbances 
of  the  bones,  joints,  muscles,  and  nails.  The  most  frequent 
situations  for  the  ulcer  are  under  the  metatarsophalangeal 
joint  of  the  great  toe  or  of  the  little  toe,  or  under  the  heel. 
The  first  local  change  is  usually  the  formation  of  a  corn, 
and  suppuration  takes  place  beneath  this  ;  an  ulcer  is  thus 
formed,  surrounded  by  an  edge  of  thickened  skin  ;  the 
ulcer  penetrates  the  soft  parts,  and  reaching  the  bones 
gives  rise  to  necrosis.  A  diffuse  cellulitis  may  originate 
in  the  ulcer  and  spread  to  the  tissues  of  the  foot. 

The  Diagnosis  is  readily  made  from  the  characteristic 
appearance  and  situation  of  the  ulcer.  Its  painlessness 
and  other  characters  differentiate  it  from  other  forms  of 
ulceration. 

INDICATIONS   FOR   OPERATION. 

The  ulcer  may  be  attacked  directly,  or  the  internal 
plantar  nerve  may  be  stretched,  with  a  view  to  bringing 
about  healing.  These  two  procedures  are  often  combined. 
Operation  should  be  done  when  the  ulcer  does  not  improve 
in  spite  of  immobilization  of  the  foot,  when,  in  spite  of  all 
care,  infection  and  complications  threaten,  and  when  the 
condition  returns  again  and  again  after  treatment.  In 
the  working  classes  especially,  operation  will  be  called  for, 
on  account  of  the  impossibility  of  keeping  the  foot  at  rest 
for  a  long  period. 

Prognosis. — Results  of  operation. — Chipault  and  his 
colleagues  have  recorded  many  cases  of  healing  after 
nerve  extension  (Chalais  collected  15  cases,  14  of  which 
were  successful)  ;  I  have  also  seen  favourable  results 
follow  the  operation.  In  one  of  my  patients  who  had  had 
a  perforating  ulcer  for  several  years,  recovery  took  place 
after  operation,  and  there  was  no  recurrence  two  and  a  half 
years  after,  although  he  walked  a  great  deal. 


DISEASES    OF    THE    PERIPHERAL    NERVES.         77 

The  risks  of  the  operation  are  small.  The  stretching  of 
the  nerve  gives  rise  to  only  transitory  paralytic  phenomena. 
In  one  case  pain  was  complained  of  in  the  area  of  the 
posterior  tibial  nerve,  and  in  another  ansesthesia  of  the 
foot  was  present  for  some  months.  One  case  of  rupture  of 
the  nerve  has  been  recorded. 

If  no  operation  he  done  the  ulcer  is  liable  to  be  complicated 
by  extensive  cellulitis,  and  septicaemia  and  pyaemia  are  not 
uncommon.  In  a  case  which  I  have  recently  seen,  a  local 
cellulitis  supervened,  and  was  complicated  by  arthritis 
of  five  of  the  large  joints. 

LITERATURE. 

Borchard-Nasse.  Handbuch  der  prakt.  Chir.  von  Bruns, 
Bergmann,  u.  Mikulicz.     Bd.  iv.,  T.  2,  p.  647. 

WiNiWATER.     Deutsche  Chirurgie. 

H.   ScHLESiNSER.     Die  Syringomyelie.     2nd  Ed.     Wien.      1902. 

Bergmakn.     Die  Lepra.     Deutsche  Chirurgie. 

Recklinghausen.     Spina  Bifida.     Virch.   Arch.,   cv. 

Chipault  u.  seine  Schiiler.  Travaux  de  Neurologic  Chirurgicale. 
4th  and  5th  Ser.     Paris.      1899,  1902. 

Chalais.     Traitement  du  Mai  Perforant.  These  de  Paris.      1897. 


CHAPTER     IV. 
Neuroses. 


Chapter   IV. 

NEUROSES. 

EXOPHTHALMIC     GOITRE. 

Etiology. — This  affection  often  develops  in  "  nervous  " 
individuals.  Its  appearance  is  often  preceded  by  some 
violent  emotional  disturbance  or  fright.  Direct  heredity 
is  rarely  traceable  ;  exhausting  diseases  somewhat 
frequently  appear  to  be  the  causative  factor  ;  sometimes 
it  follows  chronic  intoxications. 

Clinical  Course. — When  fully  developed  the  disease 
exhibits  the  following  cardinal  signs  :  exophthalmos, 
a  vascular  goitre,  and  tachycardia.  In  addition  to 
exophthalmos,  other  eye  symptoms  occur  :  Graefe's 
symptom,  diminution  of  the  movements  of  the  lids 
(Stellwag's  symptom),  and  weakness  of  the  muscles  of 
convergence  (Moebius'  symptom).  The  goitre  is  often 
very  soft  and  compressible  ;  it  pulsates,  and  a  bruit 
and  thrill  are  usually  present.  Pulsation  is  usually 
prominent  throughout  the  arterial  system,  and  bruits  can 
•often  be  heard  in  these  vessels.  Frequently  the  patient 
exhibits  tremors  of  the  fingers,  states  of  depression  and 
exaltation,  loss  of  appetite,  attacks  of  profuse  diarrhoea, 
and  excessive  perspiration.  The  galvanic  conductibility 
of  the  skin  is  usually  diminished.  The  patient  often  loses 
flesh  early  ;  less  commonly  marked  pigmentation  of  the 
skin  is  found,  and  oedema,  either  transitory  or  persistent, 
in  the  latter  case  of  cardiac  origin. 

Exophthalmic  goitre  is  said  to  be  secondary  when  its 
characteristic  symptoms  develop  some  considerable  time 
after  the  appearance  of  the  actual  goitre  ;  primary  when 
the  latter  appears  at  the  same  time  as  the  other  symptoms. 
Sometimes  the  development  of  the  symptoms  takes  place 
in  an  acute  form  ;  occasionally  one  or  other  of  the  cardinal 
symptoms  is  absent. 

6 


82  INDICATIONS    FOR    OPERATION    IN 

Differential  diagnosis. — Goitre,  complicated  by  pressure 
on  the  sympathetic,  is  with  difficulty  distinguished  from 
true  Graves'  disease.  In  such  cases,  however,  the  goitre 
does  not  show  the  vascular  phenomena  characteristic  of 
Graves'  disease,  the  sympathetic  symptoms  are  one-sided, 
and  signs  of  pressure  on  trachea  and  oesophagus  are  present. 
In  some  highly  nervous  individuals  with  goitre  or  exoph- 
thalmos it  is  sometimes  difficult  to  be  sure  whether  one 
has  to  deal  with  one  of  those  forms  of  true  exophthalmic 
goitre,  to  which  reference  has  already  been  made,  in  which 
one  or  other  of  the  cardinal  symptoms  is  absent. 

INDICATIONS    FOR   OPERATION. 

There  is  much  disagreement  among  different  writers 
as  to  the  advisability  of  operation.  While  some,  for 
example  Lemke  and  Kocher,  recommend  operation  in  all 
cases,  others  (Buschan)  do  not  advise  it  under  any  conditions. 
The  majority  hold  that  under  certain  circumstances  it  is 
to  be  recommended.  The  presence  of  a  voluminous  goitre 
giving  rise  to  symptoms  which  threaten  to  be  fatal,  such 
as  tracheal  compression,  is  an  absolute  indication  for 
operation  ;  in  such  a  case  I  have  had  to  perform  immediate 
tracheotomy.  Operation  is  also  absolutely  indicated  in 
acute  Graves'  disease,  where  the  symptoms  are  making 
rapid  progress. 

Most  authorities  agree  (a)  That  no  operation  should  be 
done  in  ordinary  cases,  unless  internal  medication  has  been 
tried  and  failed,  since  spontaneous  recovery  takes  place 
not  infrequently  ;  (b)  That  operation  should  be  undertaken 
in  severe  cases,  provided  that  the  patient's  general 
condition  is  good,  and  that  signs  of  commencing  cachexia 
indicate  early  operation  (Sorgo). 

Certain  external  conditions  may  also  render  operation 
advisable  :  when  the  patient  cannot  take  proper  care  of 
himself,  when  he  is  unable  to  continue  his  work,  and  when 
he  himself  has  a  fixed  desire  for  the  operation.  A  hard, 
goitrous  tumour  superiicially  situated  is  a  recommendation 
to  operation.  According  to  Sorgo,  a  case  must  be  considered 
severe,  and  therefore  suitable  for  operation  (a)  When  some 
particular  symptom  is  present  in  a  very  pronounced  form  : 
for  example,  excessive  exophthalmos  indicates  the  advisa- 
bility o;  resection  of  the  sympathetic  ;    a  very  voluminous 


NEUROSES.  83 

goitre  may  render  operation  necessary  for  the  relief  of 
signs  of  compression  ;  (b)  When  the  disease  progresses 
with  marked  rapidity  ;  (c)  When  some  comphcation 
threatens  hfe,  for  example,  cachexia,  degeneration  of 
cardiac  muscle,  disorders  of  the  nervous  system,  etc. 

According  to  Kocher,  the  rational  operative  procedure 
for  exophthalmic  goitre  consists  in  a  partial  excision  with 
ligature  of  the  afferent  arteries,  often  necessarily  completed 
in  several  stages.  Exothyreopexy  and  resection  of  the 
sympathetic  do  not  give  such  good  results. 

Contra-indications. — These  have  already  been  discussed. 
Advanced  cachexia  is  against  operation.  Considering  ihe 
considerable  risks  attached  to  operation,  internal  medication 
should  first  be  tried  in  all  cases,  although  Kocher  holds  a 
contrary  opinion. 

Prognosis. — The  risks  of  operation. — Often,  either  during 
or  after  operation,  very  unpleasant  and  dangerous  symptoms 
supervene,  which  are  attributable  on  the  one  hand  to  a 
lessened  resistance  of  the  organism,  and  on  the  other  to 
the  increased  excitability  of  the  nervous  centres.  On 
several  occasions  sudden  death  has  occurred,  and  in  other 
cases  collapse  and  symptoms  of  severe  general  disturbance, 
tachycardia,  and  fever.  A  general  anaesthetic  is  much 
more  dangerous  in  a  case  of  Graves'  disease  than  in  a 
case  of  simple  goitre  ;  for  this  reason  Kocher  advises  that 
all  cases  should  be  operated  on  without  a  general  anaesthetic. 
Previous  treatment  with  iodine,  or  thyroid  extract,  makes 
the  prognosis  of  operation  worse,  and  the  same  is  true  of 
free  haemorrhage  at  the  operation. 

Results  of  operation. — By  operation,  or  rather  by  several 
consecutive  operations,  the  symptoms  are  often  so  improved 
that  one  is  justified  in  speaking  of  actual  cure.  In  a 
quarter  of  the  published  cases  of  the  individual  symptoms, 
the  tachycardia  and  the  exophthalmos  were  improved. 
Of  the  whole  number  in  Sorgo's  statistics,  half  (51  "2  per 
cent)  were  improved,  a  fourth  (27-9  per  cent)  cured,  6*4 
per  cent  were  not  benefited  or  became  worse,  and  I3"9 
per  cent  died  either  during  or  directly  after  the  operation. 
The  results  are  not  worse  in  primary  than  in  secondary 
cases. 

//  no  operation  be  done,  the  prognosis  is  guided  by  the 
following  considerations  :    the  disease  is  essentially  chronic, 


84  INDICATIONS    FOR    OPERATION    IN 

and  causes  death  in  only  a  small  proportion  of  cases  by 
cachexia  or  some  other  complication  ;  even  in  its  severe 
types  spontaneous  recovery  may  occur  ;  in  many  cases 
the  patient  is  quite  unable  to  apply  herself  to  any  occupation 
or  to  enjoy  life  in  any  way.  The  acute  cases,  happily  rare, 
run  a  relatively  malignant  course,  and  cause  death  in  a 
higher  percentage  of  cases. 

LITERATURE. 

J.  Sorgo.  Die  operative  Behandlung  d.  Basedow's  Krankheit, 
Zentralb.  f.  d.  Grenzgcbiete  d.  Med.  u.  Chir       1898. 

A.  KocHER  Ueber  Morbus  Basedowii.  Mitteil.  a.  d.  Grenz- 
gebiete  d.  Med.  u.  Chir.     Bd  ix.,  Hf.  i  and  2. 

BuscHAN.     Die    Basedow'sche     Krankheit.     Wien.      1894. 

MoEBius.     Die    Basedow'sche    Krankheit. 

Nothxagel's  Handbuch  d.  spez.  Pathol,  u.  Therap.      Wien. 

MoEBius.  Ueber  die  Operation  beim  ^Morbus  Basedowii .  Miinch. 
med.  Wochens.     Xo.    i,    1899. 


INTERMITTENT     HYDRARTHROSIS. 

Definition. — Intermittent  hydrarthrosis  is  a  designation 
used  for  cases  in  which  distension  of  joints  with  fluid  occurs 
at  regular  or  irregular  intervals  without  leaving  any 
permanent  anatomical  changes. 

Etiology. — This  affection  usually  occurs  in  "  nervous  " 
individuals  following  some  slight  trauma,  or  some  infection 
or  intoxication.  It  usually  occurs  between  the  ages  of 
ten  and  forty. 

Clinical  Course. — After  some  prodromal  symptoms  one 
or  more  joints  become  swollen  without  any  accompanying 
fever.  The  effusion  persists  for  several  days  and  then 
disappears  spontaneously,  and  this  process  repeats  itself  at 
intervals.  As  a  rule  the  knee  is  affected,  either  alone,  or 
with  other  joints  ;  in  sixty-four  cases  which  I  collected, 
only  twice  was  the  knee  unaffected.  The  pain  is  sometimes 
intense  and  radiates  to  the  regional  nerves .  There  is  no  heart 
lesion.  Often  there  are  various  nervous  phenomena,  and 
sometimes  there  are  circumscribed  oedematous  swellings  of 
the  skin  in  other  situations.  The  attacks  sometimes  show 
a  definite  relation  to  the  physiological  genital  functions  in 
their  onset  and  their  disappearance.  The  affection  may 
persist  for  several  years. 


NEUROSES.  85 

INDICATIONS   FOR  OPERATION. 

Operation  will  be  done  only  as  a  last  resource,  when  all 
internal  medical  treatment  has  failed.  Relatively  good 
results  have  been  obtained  by  puncture  of  the  joint  and 
injection  of  some  irritating  fluid. 

Contra-indications.- — No  operation  will  be  recommended 
when  the  affection  has  been  present  for  only  a  short  time  ; 
when  it  does  not  always  attack  one  joint,  but  first  one  and 
then  another  ;  and  when  medical  treatment  has  not  been 
given  a  proper  trial  (arsenic,  electric  current,  etc.). 

Prognosis.— i?esM//s  of  operation.- — Operative  treatment 
is  unsuccessful  in  a  relatively  large  proportion  of  cases  ; 
the  process  itself  may  not  be  improved,  or  may  reappear 
in  another  joint.  In  one  of  my  cases,  puncture  of  the 
knee,  repeated  twice,  had  no  influence  either  on  the 
recurrence  of  the  effusion,  or  on  the  severity  of  the  attacks. 

Without  operation  the  attacks  may  recur  for  many  years  ; 
sometimes  they  disappear  suddenly  ;  n  other  cases  there 
may  be  long  periods  (notably  during  pregnancy)  during 
which  they  remain  absent  ;  in  others  the  effusion  suddenly 
passes  to  other  joints. 

LITERATURE. 

H.  ScHLESiNGER.  Die  intermit-f.  Gelenksschwellungen.  Xoth- 
nagel's  Handbuch  d.  spez.  Pathol,  u.  Therap.  Bd.  vii.,  Part  2. 
Wien.      1903. 


CHAPTER     V. 
Diseases    of   the    Larynx. 


89 


Chapter  V. 

DISEASES     OF     THE    LARYNX. 

STENOSIS   OF    THE    LARYNX. 

Etiology. — A  variety  of  causes  may  give  rise  to- 
laryngeal  stenosis.  In  addition  to  diphtheria  and  certain 
nervous  affections,  there  must  be  mentioned  cedema 
of  the  larynx,  syphilis,  rhinoscleroma,  tuberculosis,  new 
growths  and  scars,  and  perichondritis  laryngea. 

Clinical  Signs. — Laryngeal  stenosis  may  be  acute,, 
subacute,  or  chronic.  According  to  the  rapidity  with  which 
the  stenosis  supervenes,  one  or  other  symptom  may  pre- 
dominate. When  it  rapidly  becomes  extreme,  signs  of 
suffocation  appear,  the  auxiliary  muscles  of  respiration  are 
called  upon,  the  larynx  descends  deeply  at  inspiration,  and 
inspiratory  and  often  expiratory  stridor  are  noticed. 
The  laryngoscope  often  demonstrates  the  cause  of  the 
stenosis.  If  the  onset  is  gradual,  dyspnoea  may  be  slight 
and  only  noticeable  on  exertion,  but  when  the  channel  is 
narrowed,  difficulty  in  respiration  may  come  on  at  any  time 
from  the  impaction  of  pledgets  of  mucus  or  crusts. 

Differential  diagnosis. — The  site  of  obstruction  can  be 
demonstrated  with  the  laryngoscope  ;  when  stenosis  is 
laryngeal  the  voice  is  often  affected. 

INDICATIONS   FOR   OPERATION    (extra-laryngeal). 

It  is  necessary  to  open  the  larynx  or  trachea,  (i)  When 
dyspnoea  is  intense,  whether  the  stenosis  is  of  acute  or 
chronic  onset  ;  (2)  In  cicatricial  stenosis,  where  tracheotomy 
is  employed  for  systematic  dilatation  with  metal  or  rubber 
instruments  ;  (3)  In  tumours  of  the  larynx  for  the  purpose 
of  extirpation. 

Contra-indications. — There  are  no  contra-indications  under 
the  first  heading  given  above.  Systematic  dilatation  is 
a  tedious  proceeding,  and  may  be  contra-indicated  by  an 


90  INDICATIONS    FOR    OPERATION   IN 

indifferent  general  state  of  health.  Sloughing  and  necrosis 
of  laryngeal  growths  contra-indicate  tracheotomy  unless 
suffocation  threatens. 

Prognosis. — Results  of  operation. — Tracheotomy  often 
saves  life.  The  dilatation  of  stenosis  through  a  tracheal 
wound  is  often  successful  in  restoring  the  laryngeal  passage. 
The  possibility  of  removing  a  laryngeal  or  tracheal  growth  by 
operation  within  the  channel  will  depend  upon  its  extent 
and  infiltration.  When  these  are  marked,  a  more  radical 
proceeding  will  be  necessary. 

Risks  of  operation. — The  risks  of  tracheotomy  as  such 
are  very  small  in  competent  hands.  However,  when  some 
septic  process  is  present  in  the  larynx,  tracheotomy  is  not 
uncommonly  followed  by  pneumonia  or  gangrene  in  the 
lungs. 

LITERATURE. 

V.    ScHROTTER.      Kehlkopfkrankheitcn.     Wien,    1892. 

Stork.  Krankheiten  des  Kehlkopfes.  Nothnagel's  Handbuch 
d.  spez.  Pathol.     Bd.  xiii. 

Strubing.  Krankheiten  des  Kehlkopfes.  Handbuch  d.  prakt. 
Med.  von  Ebstein-Schwalbe.     Stuttgart,  1899. 

Heymanx.     Handbuch    der    Kehlkopfkrankheitcn. 


LARYNGEAL    PARALYSIS   OF    NERVOUS    ORIGIN. 

Etiology. — Bilateral  paralysis  of  the  abductor  muscles 
may  be  due  to  a  central  or  a  peripheral  cause.  Most  often 
it  follows  tabes  dorsalis.  In  all  other  central  lesions 
involving  the  bulb  (syringobulbar  paralysis,  progressive 
muscular  atrophy),  laryngeal  paralysis  is  exceptional,  and 
it  is  also  rare  in  lead  neuritis  and  other  peripheral  paralyses. 

Clinical  Course. — The  bilateral  laryngeal  paralyses 
are  the  only  laryngeal  nervous  paralyses  of  surgical  interest. 
Of  this  group,  bilateral  recurrent  laryngeal  paralysis,  a  rare 
lesion,  has  not  hitherto  been  submitted  to  any  surgical 
treatment,  for  it  gives  rise  to  little  interference  with 
respiration  or  deglutition.  In  two  of  my  cases  the  glottis 
was  fixed  in  the  mid  position.  There  was  slight  stridor  on 
deep  respiration,  and  occasional  difficulty  in  swallowing. 
Bilateral  paralysis  of  the  crico-arytenoids  is,  on  the  other 
hand,  of  surgical  importance.  The  glottis  is  reduced  to  a 
small  slit,  and  on  inspiration  the  vocal  cords  come  together  ; 


DISEASES   OF    THE   LARYNX.    ,  91 

this  gives  rise  to  dyspnoea,  always  inspiratory  in  character. 
Inspiration  is  stridulous  ;  the  voice,  however,  is  unchanged, 
and  may  be  quite  clear  and  distinct.  In  many  cases  the 
degree  of  dyspnoea  is  small,  and  causes  little  distress. 

Diagnosis. — The  affection  is  easily  diagnosed  when  the 
contrast  between  the  signs  of  inspiratory  obstruction  and 
the  absence  of  any  interference  with  the  voice  is  noticed  ; 
laryngoscopy  will  at  once  reveal  the  nature  of  the  lesion. 

INDICATIONS  FOR  OPERATION. 

According  to  present  knowledge,  tracheotomy  is  the  only 
surgical  procedure  indicated.  It  may  be  called  for  as  a 
last  resource  when  repeated  attacks  of  dyspnoea  threaten 
asphyxia,  or  when  the  narrowing  of  the  glottis  is  extreme 
from  swelling  of  the  cords.  Secondly,  it  may  be  indicated 
as  a  prophylactic  measure  .when  the  patient,  subject  to 
these  dyspnoeic  attacks,  is  so  circumstanced  that  he  is 
unable  to  obtain  immediate  surgical  assistance  if  he  should 
need  it. 

Contra-indications. — When  dyspnoea  is  slight,  and  when 
assistance  can  be  counted  on  in  an  emergency,  operation 
is  not  called  for. 

Prognosis. — Of  operation. — Tracheotomy  only  relieves 
the  dyspnoea  ;  it  has  no  effect  on  the  lesion  ;  as  a  rule  the 
cannula  has  to  be  worn  permanently. 

When  no  operation  is  undertaken,  marked  narrowing  of  the 
glottis  is  astonishingly  well  borne  if  the  paralysis  supervenes 
gradually  and  if  secondary  contractures  develop  slowly. 
One  of  my  patients  was  entirely  without  any  subjective 
sensation  of  dyspnoea  when  sitting,  and  even  when  walking 
slowly,  although  he  had  to  be  excluded  from  the  general  ward 
on  account  of  his  loud  inspiratory  stridor,  which  could  be 
heard  on  a  quiet  night  in  a  court-yard  at  a  considerable 
distance  from  his  room.  In  my  experience  tracheotomy  is 
rarely  necessary  in  this  affection  if  the  patient  remains 
under  medical  supervision  and  avoids  over-exertion. 

LITERATURE. 

Sp:mon.  Nervenkrankheiten  des  Kehlkopfes.  Handbuch  d. 
Laryng.   von   Heymann.     Bd.   i. 

GoTTSTEiN.      Krankheiten   des    Kehlkopfes.     4th    Ed       189,5. 
ScHECH.     Die    Krankheiten  des   Kehlkopfes.     Wicn,    1897. 


92  INDICATIONS    FOR    OPERATION    IN 

DIPHTHERIA. 

Etiology. — Infection  with  the  diphtheria  bacillus  takes 
place  usually  through  the  tonsils,  more  rarely  through 
the  nose,  pharynx,  and  larynx.  Almost  always  there  is  a 
mixed  infection  with  streptococci. 

Pathological  Anatomy. — Locally  the  affected  area 
shows  inflammatory  changes  going  on  to  necrosis  and  the 
formation  of  adherent  membrane.  The  local  necrosis 
often  causes  considerable  destruction  by  deep  penetration. 
There  may  be  more  or  less  free  membrane  in  the  pharynx 
and  larynx.  The  neighbouring  lymph  glands  are  usually 
enlarged.  In  about  20  per  cent  of  cases  there  is  myocarditis 
and  consequent  degeneration  of  the  heart  muscle.  Bac- 
teriology has  shown  that  there  is  no  true  distinction  between 
diphtheria  and  the  so-called  croup. 

Clinical  Course. — In  the  milder  cases  there  is  moderate 
pyrexia,  the  tonsils,  uvula,  and  soft  palate  are  dusky  red, 
and  show  membrane  at  first  in  discrete  spots,  and  later 
confluent  ;  this  membrane  may  extend  over  the  pharyngeal 
wall,  to  the  nose  and  to  the  larynx.  When  the  nose  is 
involved  there  is  a  blood-stained  discharge,  nasal  respiration 
is  obstructed,  the  whole  nose  is  swollen,  and  whitish  or 
greyish  particles  of  membrane  may  be  seen  in  the  nostrils. 
The  larynx  is  especially  often  involved  in  "  malignant  " 
diphtheria. 

The  malignant  or  septic  form  develops  rapidly,  with 
severe  general  symptoms.  The  lymphatic  glands  are  early 
swollen  and  tender.  Within  the  first  three  days  the  patches 
of  membrane  are  replaced  by  septic  gangrenous  ulcers, 
bleeding  easily  and  foul  smelling.  The  temperature  is 
usually  high,  but  occasionally  subnormal.  The  pulse 
rapidly  weakens,  and  the  profound  intoxication  induces 
delirium,  stupor,  and  paralyses,  with  increasing  cyanosis 
and  marked  renal  changes.  Death  occurs  in  very  many  of 
these  cases. 

When  the  larynx  is  involved  the  voice  is  changed  and 
cough  is  troublesome  ;  inspiratory  stridor  (croup)  is  usually 
noticed  about  the  second  or  third  day,  and  membrane  is 
seen  on  the  cords  with  the  laryngoscope.  In  true  diphtheria, 
however,  the  pharynx,  larynx,  and  trachea  may  show  only 
catarrhal  swelling.     With  increase  in  the  obstruction  of  the 


DISEASES   OF    THE   LARYNX.  93 

glottis,  dyspnoea  becomes  more  intense  ;  occasionally  the 
patient  may  have  temporary  relief  after  coughing  up 
membrane.  When  untreated,  a  patient  with  laryngeal 
diphtheria  usually  dies  in  from  four  to  seven  days  with 
symptoms  of  asphyxia.  Sometimes  the  process  extends 
into  the  bronchi,  but  no  peculiar  symptoms  other  than 
those  of  laryngeal  diphtheria  arise  from  this  extension. 
When  recovery  occurs  in  the  severe  type  of  the  disease, 
convalescence  often  takes  many  weeks. 

Diagnosis  and  Differential  Diagnosis. — Bacterio- 
logical examination,  and  the  fact  that  the  posterior  pharyngeal 
wall  is  often  as  much  involved  as  the  tonsils,  serve  to 
distinguish  diphtheria  from  follicular  tonsillitis.  With 
regard  to  pseudo-croup^  the  attacks  in  this  affection  occur 
at  night,  respiration  is  unaffected  during  the  day,  the  attacks 
are  short,  and  there  is  no  membrane  in  the  larynx.  The 
aspiration  of  foreign  bodies  has  often  given  rise  to  a  mistaken 
diagnosis  of  diphtheria. 

INDICATIONS   FOR  OPERATION. 

Indications  for  operation  have  been  formulated  by  many 
authors  ;  some  favour  the  early  and  others  the  late  operation. 
Baginsky  advises  operation  when  inspiration  is  prolonged, 
expiration  noisy,  and  the  chest  is  indrawn,  also  when  attacks 
of  dyspnoea  occur,  even  in  a  moderate  degree,  with  sensa- 
tions of  apprehension.  One  should  never  await  the  onset 
of  signs  of  asphyxia,  cyanosis,  or  pallor,  coldness  of 
the  extremities,  and  diminution  of  cutaneous  sensibility 
(Baginsky).  Most  writers  advocate  early  operation.  This 
surgical  intervention  may  take  the  form  of  intubation  or 
tracheotomy.  It  should  be  a  rule  to  practise  intubation 
primarily,  when  the  respiratory  difficulty  appears.  It  may 
be  adopted  as  a  secondary  measure  when,  after  tracheotomy, 
it  is  found  difficult  to  remove  the  cannula.  If  intubation 
cannot  be  done  for  any  reason,  then  tracheotomy  must  be 
the  primary  procedure.  If  intubation  does  not  relieve  the 
breathing,  tracheotomy  should  follow,  and  this  may  be  also 
necessitated  by  repeated  coughing  out  of  the  intubation 
tube,  by  the  presence  of  pneumonia,  by  difficulties  in 
feeding,  by  blockage  of  the  tube  and  threatening  suffocation, 
and  by  the  breaking  of  the  thread  attached  to  the  tube 
and  the  impossibility  of  expressing  it.     Generally,  it  may 


94  INDICATIONS    FOR    OPERATION    IN 

be  said  that  primary  tracheotomy  should  be  done  when  the 
following  signs  are  present  :  asphyxia  and  pronounced 
heart  failure,  marked  infiltration  and  oedema  of  the  soft 
parts  about  the  entrance  to  pharynx  and  larynx,  retro- 
pharyngeal abscess.  It  is  also  indicated  when  the  patient 
is  not  in  hospital,  and  surgical  aid  is  not  immediately 
available.  The  recommendation  of  primary  tracheotomy 
in  cases  where  the  diphtheritic  process  has  extended  far 
into  the  trachea  is  largely  theoretical  ;  this  can  rarely  be 
recognized  until  the  trachea  has  been  actually  opened. 

Intubation  versus  Tracheotomy. — Intubation  is  a  relatively 
insignificant  procedure,  and  can  usually  be  easily  and  rapidly 
performed.  No  anaesthetic  or  assistants  are  necessary  ; 
there  is  no  risk  of  haemorrhage,  which  may  be  troublesome 
during  and  after  tracheotomy  ;  and  there  is  no  wound  to 
be  infected  (Ganghofner).  Treatment  is  less  prolonged 
after  intubation  than  after  tracheotomy,  and  it  is  easier 
to  gain  the  consent  of  the  relatives  to  the  former  than 
to  the  latter. 

Contra-indications. — The  contra-indications  have  been 
already  mentioned.  When  there  is  much  secretion  of 
tenacious  mucus,  tracheotomy  rather  than  intubation  is 
indicated. 

Prognosis. — Risks  of  intervention.— Intuhaition  is  an 
operation  that  requires  a  practised  hand,  and  much  damage 
may  be  done  to  the  larynx  by  unskilful  introduction  of 
the  tube.  If  the  tube  be  left  in  long  it  may  cause  ulcera- 
tion and  subsequent  cicatricial  contraction  ;  feeding  is 
somewhat  interfered  with,  and  removal  of  the  tube  may 
occasion  severe  respiratory  embarrassment.  The  latter 
may  also  be  set  up  when  the  tube  is  introduced  by  the 
pushing  down  of  membrane  into  the  trachea,  and  sometimes 
the  tube  is  coughed  out  and  the  patient  threatened  with 
suffocation. 

In  low  tracheotomy,  haemorrhage  may  be  troublesome 
both  during  and  after  operation.  Occasionally  erysipelas, 
cellulitis,  or  diphtheritic  inflammation  occurs  in  the 
tracheotomy  wound.  When  some  paralysis  of  deglutition 
appears  at  the  same  time,  pneumonia  is  to  be  feared. 

Results  of  intervention. — Intubation  and  tracheotomy 
often  save  life,  especially  in  cases  where  antidiphtheritic 
serum  is  administered,  giving  time  for  the  serum  to  produce 


DISEASES   OF    THE   LARYNX.  95 

its  curative  effect.  Secondary  intubation  is  often  very  suc- 
cessful in  overcoming  the  difficulties  attendant  on  removal 
of  the  tracheotomy  tube.  Secondary  tracheotomy, 
practised  when  intubation  fails  to  give  relief,  is  not  often 
successful,  because  in  such  cases  the  diphtheritic  process 
is  generally  descending.  The  prognosis  of  tracheotomy 
depends  very  much  on  the  character  of  the  attack.  It  is 
bad  when  the  operation  is  done  on  a  patient  in  asphyxia 
or  below  the  age  of  two  years.  The  progress  of  the  disease 
when  no  operation  is  done  has  been  referred  to  in  the 
description  of  the  clinical  course. 

LITERATURE. 

Ganghofner.  Behandlung  der  Diphtheric.  Handbuch  d.  spez. 
Therap.  von  Penzoldt-Stintzing.     Bd.  i. 

Baginsky.  Diphtheric.  Nothnagel's  Handbuch  der  spez.  PathoL 
Bd.  ii.,  Teil  i.     Wien,   1898. 

HoFMEiSTER.  Diphtheria  des  Larynx.  Handbuch  d.  prakt. 
Chir.  von  Bergmann,  Bruns,  u.  Mikulicz.  Bd.  ii.  Stuttgart, 
1900. 

Hoppe-Seyler.  Croupos-diphtheritische  Erkrankungen  des 
Larynx  u.  der  Trachea.  Heymann's  Handbuch  d.  Laryng.  u.  Rhinol. 
Bd.  i.     Wien,    1898. 


CHAPTER    VI. 

Diseases   of  the    Bronchi    and   the    Lungs. 


99 


Chapter    VI. 
DISEASES   OF   THE  BRONCHI  AXD   THE  LUXGS. 

BRONCHIECTASIS. 

Etiology. — The  most  important  etiological  factors  are 
chronic  bronchial  catarrh  and  chronic  interstitial  pneumonia, 
with  or  without  pleurisy.  Bronchiectasis  may  also  occur 
from  the  blocking  of  the  lumen  of  a  bronchus  by  scar  or 
foreign  body,  or  from  pulmonary  emphysema.  It  occurs 
rarely  as  a  congenital  condition  in  atelectatic  lungs. 

Pathological  Anatomy. — A  distinction  is  made  between 
the  common  (vicarious)  diffuse  cylindrical  and  spindle- 
shaped  form  and  the  rarer  sacciform  (inflammatory)  type. 
The  parenchyma  between  the  bronchiectatic  cavities, 
notably  in  the  sacciform  type,  is  more  or  less  shrunken  and 
destroyed.  The  changes  may  involve  a  single  bronchus 
or  a  w^hole  group  connected  with  one  or  several  pulmonary 
lobules  ;  the  size  of  the  resulting  cavity  varies  from  that  of 
a  bean  to  that  of  the  closed  fist.  The  cavity  may  lie  close 
to  the  thoracic  waU  or  near  the  hilus.  Ulcerative  processes 
occur  in  the  walls  of  the  bronchi,  giving  rise  to  haemorrhage, 
and  becoming  gangrenous  ;  sometimes  they  heal  and  form 
cicatrices.  When  the  cavity  is  superficial  and  the  lung 
much  shrunken,  pleural  adhesions  develop. 

Clinical  Signs. — Frequently  there  are  no  characteristic 
symptoms,  only  those  of  a  chronic  catarrh,  and  such  cases 
are  of  no  surgical  importance.  In  other  cases  the  signs  of 
cavity  (cf.  "Gangrene  of  the  Lung")  are  well  developed  and 
the  expectoration  is  copious.  This  expectoration  may  occur 
in  great  quantity  at  some  particular  time  of  the  day  (morning), 
or  when  the  patient  adopts  some  particular  attitude.  One 
of  my  patients  expectorated  more  than  a  litre  of  sputum 
daily  for  a  year.  The  sputum  is  purulent,  and,  when  putrid 
bronchitis  is  present,   it  is  very  foul  smelling  ;     it   forms 


loo  I^WICATIONS    FOR    OPERATION    IN 

three  layers  on  standing ;  in  uncomplicated  bronchiectasis, 
fragments  of  lung  and  elastic  tissue  are  not  found.  The 
expectoration  often  also  contains  blood.  Fever  and  loss  of 
flesh  occur  in  some  cases,  not  as  a  rule  until  the  condition 
has  been  present  for  a  considerable  time.  "Drumstick" 
lingers  and  clubbed  toes  are  often  to  be  noted.  In  long- 
standing cases  complications  are  relatively  common,  such 
as  cerebral  abscess  and  arthritis.  Amyloid  disease  is  unusual ; 
in  some  cases  there  is  an  associated  empyema. 

Diagnosis. — The  diagnosis  is  based  on  the  chronic  nature 
of  the  affection,  on  the  copious  and  characteristic  sputum, 
on  the  signs  of  cavity  more  or  less  evident  according  as 
the  cavity  is  full  or  empty  of  secretion.  Retraction  of  the 
thorax,  and  a  certain  amount  of  displacement  of  the 
neighbouring  organs  (heart)  towards  the  affected  side, 
point  to  the  presence  of  a  chronic  interstitial  pulmonary 
process  and  adhesions  between  the  pleura  and  the  thoracic 
wall,  and  support  the  diagnosis  of  bronchiectasis.  The 
physical  signs  of  cavity  will  indicate  the  situation  of  the 
lesion,  and  a  radiographic  picture  may  furnish  corroborative 
evidence. 

Differential  diagnosis. — It  is  often  difficult  to  distinguish 
this  affection  from  tuberculosis.  Absence  of  tubercle 
bacilli  and  of  elastic  fibres  from  the  sputum,  the  character 
of  the  expectoration,  the  chronic  course,  and  relatively 
good  general  condition,  will  aid  in  the  diagnosis,  and  the 
fact  that  the  apices  are  usually  only  slightly,  or  not  at  all, 
affected.  Sometimes  the  question  of  an  empyema  emptying 
itself  into  the  bronchi  may  arise ;  in  such  cases  the 
history  is  of  special  importance,  pointing  to  a  preceding 
pleuritis.  If  there  is  a  history  extending  over  a  year  or  more, 
the  condition  is  almost  certainly  a  bronchiectasis.  With 
regard  to  pulmonary  abscess,  the  history  will  also  be  of 
great  assistance ;  pneumonia  or  trauma  shortly  preceding 
will  point  to  abscess  ;  in  abscess  also,  fragments  of  lung 
tissue  are  found  in  the  sputum,  and  are  absent  in  uncom- 
plicated bronchiectasis. 

INDICATIONS   FOR   OPERATION. 

There  is  at  present  some  difference  of  opinion  as  to  the 
indications  for  the  opening  of  bronchiectatic  cavities. 
There  cannot  be  said  to  be  any  absolute  indications,  but  a 


DISEASES  OF   THE  BRONCHI   AND    THE  LUNGS.      loi 

relative  one  is  present  when  the  patient,  in  the  course  of  his 
complaint  (notably  when  it  is  complicated  by  putrid 
bronchitis),  has  to  give  up  work,  loses  flesh  rapidly,  becomes 
melancholic,  and  cannot  mix  with  his  fellows.  In  such 
cases  operation  is,  however,  only  to  be  recommended  when 
the  signs  point  to  a  single,  unilateral,  and  superficial  cavity, 
and  when  the  discharge  does  not  escape  readily.  The  large 
sacciform  cavities  of  the  lower  lobe  are  particularly  suitable 
for  operation.  If  the  cavities  are  numerous,  and  putrid 
bronchitis  is  present,  with  much  expectoration,  and  if  the 
process  is  limited  to  one  part  of  the  lung,  then  rib  resection 
over  an  area  corresponding  to  the  disease  will  favour  the 
falling  in  of  the  lung  and  cicatrization  of  the  foci. 

Contra-indications. — No  operation  should  be  advised 
when  both  lungs  are  affected,  when  the  condition,  although 
confined  to  one  lung,  is  very  extensive,  when  the  cavity  is 
deep-seated,  when  the  general  condition  is  good  and  there 
is  no  putrid  bronchitis,  and  when  waxy  disease  is  well  estab- 
lished. Operation  may  be  useless  from  the  development 
of  further  cavities,  and  the  thoracic  fistula  that  is  established 
may  not  be  any  improvement  on  his  former  condition. 
In  one  of  my  cases  the  cavity  was  exactly  localized  and 
was  opened ;  after  several  months  other  cavities  had 
formed  to  such  an  extent  that  his  troubles  were  equal  to 
those  before  operation,  with  the  addition  of  a  thoracic 
iistula. 

Prognosis. — Risks  of  operation. — The  operation  and  its 
consequences  must  be  considered  serious ;  Tufher's  statistics 
show  a  mortality  of  about  25  per  cent.  In  view  of  these 
risks  it  should  be  remembered  that  bronchiectasis  is 
compatible  with  long  life.  Rib  resection  (Quincke)  is  not 
a  procedure  attended  with  any  particular  risk. 

Prognosis  of  operation. — Complete  healing  of  a  cavity 
by  operation  has  been  only  exceptionally  obtained.  As  a 
rule  the  cavity  gradually  shrinks,  but  a  fistula  persists. 
Rib  resection  may  be  followed  by  a  good  result  when  the 
disease  is  limited  to  a  small  area.  In  addition  to  the 
statistics  of  Tuffier  already  quoted,  Garre  has  reported 
fifty-seven  cases  of  operation  by  opening  the  cavity ;  of 
these  twenty-one  died,  either  immediately  after  or  within 
the  first  week. 

Without  operation  the  cavity   increases  in  size,  but  this 


I02  INDICATIONS    FOR    OPERATION    IN 

brings  no  risk  to  life,  and  waxy  disease  or  other  complications 
may  not  occur  for  many  years. 

LITERATURE. 

Quincke.  Ueber  Pneumotomie.  Mitteil.  a.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     Bd.  i. 

TuFFiER.     Chirurgie  du  Poumon.     Paris,  1897. 

Terrier  et  Reymoxd.  Chirurgie  de  la  Plevre  et  du  Poumon. 
Paris,  1899. 

Hoffmann.  Erkrankungen  der  Bronchien.  Nothnagel's  Hand- 
buch  d.  spez.  Pathol.     Wien. 


GANGRENE    OF    THE    LUNG. 

Etiology. — Gangrene  of  the  lung  most  frequently  occurs 
as  a  direct  consequence  of  pneumonia.  Tuffier  records 
seventy-four  cases  operated  on,  fifty-five  of  which  followed 
pneumonia.  Predisposing  causes  are  chronic  alcoholism, 
exhausting  diseases,  diabetes  mellitus,  putrid  bronchitis. 
Pneumonia  caused  by  the  aspiration  of  foreign  bodies  is 
often  followed  by  gangrene,  and  the  same  is  true  of  the 
pneumonias  set  up  by  the  embolic  carrying  of  septic  material 
to  the  lungs  b}'  way  of  the  jugular  or  uterine  veins.  Con- 
secutive gangrene  often  occurs  when  ulcerative  and  septic 
processes  spread  to  the  lung  from  some  adjacent  site,  such 
as  the  oesophagus,  spine,  larynx,  trachea,  and  mediastinum. 

Pathological  Anatomy. — Gangrene  is  sometimes  circum- 
scribed and  sometimes  diffuse.  The  former  may  occur  as  a 
solitary  focus  or  as  multiple  foci.  In  the  latter  case  both  lungs 
may  be  affected,  but  usually  the  gangrene  is  confined  to  one. 
Following  the  necrosis  of  lung  tissue,  cavities  form,  varying 
in  size  from  that  of  a  nut  to  that  of  the  fist  ;  they  are  bor- 
dered by  sloughing  lung  tissue,  often  communicate  freely 
with  a  bronchus,  and  not  infrequently  extend  to  the  pleural 
surface.  The  large  vessels  in  the  neighbourhood  are  often 
thrombosed;  the  overlying  pleura  is  usually  inflamed;  and 
either  adhesions  form  or  pus  collects  in  the  pleural  cavity. 
When  diffuse  the  gangrenous  process  may  involve  a  whole 
lobe  ;    it  is  not  limited  by  any  suppurating  zone. 

Clinical  Course. — In  cases  of  pneumonia,  gangrene  is 
to  be  suspected  when  the  expectoration  becomes  more 
copious  and  putrid,  with  rise  of  temperature  and  increase 
of  the  cough.     In  some  cases  there  is  no  increased  fever. 


DISEASES  OF   THE  BRONCHI  AND   THE  LUNGS.     103 

The  expectoration  forms  three  layers  on  standing,  the 
lowest  of  which  contains  yellowish-grey  Dittrich's  plugs, 
and  often  black  pigmented  fragments  of  lung  tissue. 
Elastic  fibres  are  relatively  rarely  present  in  any  numbers, 
and  haemorrhages  are  not  common.  In  the  lung  the  focus 
can  often  be  located,  even  when  it  does  not  lie  superficially, 
by  the  presence  of  coarse  metallic  rales  with  or  without 
amphoric  breath  sounds.  Other  signs  of  cavity  are  often 
present :  tympanitic  percussion,  changing  to  dullness  when 
the  cavity  is  filled  with  secretion,  alternating  percussion 
note  when  the  mouth  is  opened  and  closed,  hruit  de  pot  fete. 
In  addition  to  the  symptoms  already  mentioned,  rigors  and 
sweating  are  not  uncommon.  In  cases  of  long  standing, 
metastatic  abscesses  may  appear,  in  the  brain  and  elsewhere. 
Sometimes  the  disease  resembles  enteric  fever  in  its  onset, 
with  sustained  fever,  stupor,  and  sordes  of  the  mouth  and 
lips. 

Diagnosis. — This  is  usually  easy.  The  fcetor,  associated 
with  the  presence  of  gangrenous  lung  fragments  in  the 
sputum  is  quite  characteristic.  It  is  more  difiicult  to 
localize  the  gangrenous  area  and  to  decide  whether  there 
is  a  solitary  focus  or  several.  The  signs  of  cavity  are 
those  on  which  the  local  diagnosis  must  be  based,  and  a 
radiographic  examination  may  assist. 

Differential  diagnosis. — The  condition  has  to  be  differ- 
entiated from  putrid  bronchitis  with  or  without  bronchiec- 
tasis, but  in  the  latter  fragments  of  lung  tissue  are  not 
found  in  the  sputum.  In  an  empyema  or  a  subphrenic 
abscess  which  ruptures  into  a  bronchus,  there  are  special 
percussion  and  auscultation  phenomena,  and  the  viscera 
are  displaced. 

INDICATIONS   FOR   OPERATION. 

Free  opening  of  the  cavity  is  the  only  justifiable  operation  ; 
the  exploring  needle  should  not  be  used  on  account  of  the 
risk  of  infecting  the  pleural  cavity.  When  a  circumscribed 
area  of  gangrene  is  definitely  diagnosed  the  indication  for 
operation  is  absolute.  The  presence  of  pleural  adhesions  is 
favourable  for  operation,  but  their  absence  is  no  contra- 
indication. When  all  the  diagnostic  signs  already  described 
are  present  the  fact  that  the  focus  lies  deeply  is  no  bar  to 
rjperation.     When   the  typical  signs  of  cavity  are  absent, 


I04  INDICATIONS    FOR    OPERATION    IN 

operation  should  still  be  undertaken  when  the  following 
signs  are  present  (Riegner,  A.  Frankel)  :  (a)  A  circum- 
scribed patch  of  dullness,  notably  in  the  lower  lobe,  with 
normal  lung  tissue  all  around  it;  (b)  Fragments  of  lung 
tissue  in  the  sputum  in  abundance,  coughed  up  within  a 
short  period  ;  (c)  A  shadow  in  the  skiagram  corresponding 
exactly  with  the  patch  of  dullness  revealed  by  physical 
examination. 

If  there  is  high  sustained  fever  associated  with  rigors, 
operation  should  be  done  even  when  the  focus  is  not  super- 
ficial. Operation  is  urgently  called  for  when  the  condition 
is  complicated  by  empyema,  and  also  when  the  gangrenous 
area  is  apical,  as  a  focus  in  this  situation  is  particularly 
dangerous. 

Contra-indi cations. — Even  when  the  diagnosis  is  certain, 
no  operation  should  be  done  when  the  gangrene  is  diffuse, 
when  the  foci  are  multiple,  when  the  condition  is  bilateral,  or 
when  there  already  exists  some  cerebral  or  meningeal 
lesion.  When  the  focus  is  very  small  the  case  is  not  as  a 
rule  suitable  for  operation,  because  the  diagnosis  cannot 
usually  be  definitely  settled,  and  definite  localization  must 
always  be  looked  upon  as  an  essential  preliminary.  In 
diabetics,  when  the  urine  contains  a  large  quantity  of  sugar 
and  acetone,  operation  is  inadvisable. 

Prognosis. — Of  operation. — The  earlier  the  condition  is 
operated  on,  the  better  the  prognosis.  Exploratory  puncture 
and  the  evacuation  of  the  cavity  with  a  trocar  are  very 
dangerous  procedures.  Tuffier  estimates  the  mortality 
after  pneumotomy  as  40  per  cent ;  Garre  gives  the  mortality 
of  122  cases  as  34  per  cent  ;  the  prognosis  varies  with  the 
etiology  of  the  condition.  In  post-pneumonic  gangrene 
the  mortality  is  high ;  in  cases  where  the  condition  follows 
pulmonary  embolism  it  is  still  higher.  Recovery  after 
operation  occurred  in  60  per  cent  of  Tuffier's  collected 
cases  ;  it  is  usually  complete  and  permanent.  Usually 
there  is  no  risk  of  pneumothorax,  because  in  most  cases 
there  are  pleural  adhesions. 

Prognosis  without  operation. — In  about  60  per  cent  of 
cases  death  occurs  from  exhaustion,  or  from  some  complica- 
tion such  as  brain  or  liver  abscess  or  pneumothorax.  In 
many  subacute  cases  the  depression  of  vitality  is  very 
pronounced,  and  waxy  disease  may  develop.     In  all  cases  of 


DISEASES   OF   THE   BRONCHI  AND    THE   LUNGS.      105 

circumscribed  gangrene  there  is  a  risk  of  the  process 
extending  to  other  parts  of  the  lung  by  aspiration,  or  of  a 
general  infection. 

LITERATURE. 

AuFRECHT.  Die  Lungenentziindungen.  Nothnagel's  Handbuch 
d.  spez.  Pathol.     Wien. 

KuMMEL.  Chirurgisclie  Krankheiten  d.  Lunge.  Handbuch  d. 
prakt.  Chir.  Herausgegeben  von  Bruns,  Bergmann,  u.  ^klikuHcz. 
Bd.  ii.      1900. 

Reymond.     Chirurgie  de  la  Plevre  et  du  Poumon.     Paris.      1899. 

TuFFiER.     Chirurgie  du  Poumon.     Paris.      1897. 

J.  ScHULz.  Ueber  den  Lungenabscess,  etc.  Zentralb.  f.  d. 
Grenzgebiete  d.  Med.  u.  Chir.      1901. 

RiEGNER.  Ulcerose  Lungenprozesse.  Deutsche  med.  Wochens. 
No.  29.      1902. 

Quincke,  Lenhartz,  Garre.  Mitteil.  a.  d.  Grenzgebiete  d.  Med. 
u.  Chir.     Bd.  ix.,  H.  3. 


ABSCESS   OF    THE    LUNG. 

Etiology. — Pneumonia  is  the  most  common  antecedent 
of  pulmonary  abscess,  and  its  occurrence  is  favoured  by 
previously  existing  emphysema  or  induration  processes. 
Abscess  also  occurs  from  embolism,  especially  in  pyaemia  and 
puerperal  sepsis ;  also  from  wounds  and  the  introduction  of 
foreign  bodies  into  the  bronchi. 

Pathological  Anatomy. — With  the  exception  of  the 
post-pneumonic  cases,  abscess  arises  in. lungs  previously 
healthy.  The  pneumonic  abscesses  are  usually  situated  in 
the  lower  lobe,  those  due  to  foreign  bodies  develop  wherever 
the  foreign  body  lodges,  and  this  usually  occurs  in  the  right 
primary  bronchus  or  in  a  secondary  bronchus  in  the  right 
lower  lobe.  Abscesses  may  be  single  or  multiple,  and  in 
size  vary  from  that  of  a  nut  to  that  of  the  fist.  The 
antecedent  pneumonia  is  often  due  to  the  Fraenkel- 
Weichselbaum  diplococcus  or  the  influenza  bacillus,  but 
in  many  cases  to  organisms  other  than  these.  In  recent 
abscesses  the  walls  fall  in  when  the  contents  are  evacuated  ; 
the  pus  may  be  inodorous,  but  in  cases  where  there  is 
associated  gangrene  it  is  foul  smelling.  In  abscesses  of 
long  standing  the  walls  are  infiltrated  and  dense.  Lung 
abscesses  may  be  near  the  surface  or  deeply  situated  ;  in 
tlie    former    then^    is    usually    })leurisy    with    adhesions    or 


io6  INDICATIONS    FOR    OPERATION    IN 

purulent  effusion,  but  in  many  cases  there  is  no  pleurisy 
at  all. 

Clinical  Course. — There  are  local  and  general  symptoms. 
Of  the  latter  a  sustained  pyrexia  is  the  most  important. 
In  cases  following  pneumonia  the  temperature  may  remain 
up,  or  pyrexia  may  set  in  again  after  the  crisis.  At  the 
same  time,  or  shortly  after,  the  patient  expectorates  in 
considerable  quantities  a  purulent  creamy  secretion,  often 
possessing  a  somewhat  sweetish  smell.  In  this  pus  there 
are  often  fragments  of  lung  tissue  and  elastic  fibres  in 
considerable  amount,  hcematoidin  crystals  and  fat  crystals. 
Physical  signs  of  cavity  are  often  not  to  be  found  when 
an  abscess  is  deep-seated,  or  may  develop  while  the  patient 
is  under  observation.  A  change  in  percussion  note  at  one 
spot,  from  dull  to  tympanitic,  after  the  patient  has  got  rid 
of  a  quantity  of  expectoration,  associated  with  bronchial 
breathing  and  the  other  various  signs  of  cavity,  may  be 
looked  upon  as  diagnostic.  In  many  cases,  however, 
especially  when  the  abscess  is  in  the  lower  lobe,  the  signs 
of  cavity  are  wanting,  owing  to  collapse  of  the  walls  when 
the  collection  of  pus  is  discharged.  When,  after  pneumonia, 
a  circumscribed  patch  of  dullness  persists,  surrounded  by 
normal  lung  tissue,  if  the  expectoration  is  abundant  and 
purulent,  if  fever  persists  and  if  a  skiagram  shows  a  shadow 
corresponding  to  the  dull  area,  a  diagnosis  of  abscess  may 
be  confidently  made. 

Diagnosis. — Radiography  is  a  valuable  aid  in  localizing 
an  abscess  ;  when  clinical  signs  suggest  multiple  abscesses 
it  may  also  be  of  much  assistance.  When  an  abscess  is 
due  to  the  presence  of  a  foreign  body,  this  may  be  seen  in  a 
skiagram  while  the  process  is  in  an  early  stage.  In  a 
recent  abscess,  if  the  sputum  becomes  foetid,  this  points  to 
its  extension  by  gangrene  of  the  wall.  The  following 
signs  point  to  the  presence  of  pleural  adhesions  around  an 
abscess  :  relative  immobility  of  the  ribs  over  a  limited 
area,  with  inspiratory  retraction  of  the  intercostal  spaces 
over  the  same  area;  lessened  inspiratory  movement  of  the 
lower  border  of  the  lung;  no  alteration  in  heart  dullness 
on  deep  inspiration  and  maximal  expiration.  When  there 
has  been  antecedent  pleuritis,  adhesions  are  probably 
present. 

The  differential  diagnosis    does    not,   as    a    rule,  present 


DISEASES  OF   THE  BRONCHI  AND    THE  LUNGS.      107 

any  particular  difficulty.  Against  bronchorrhoea  are  the 
signs  of  cavity,  and  the  presence  of  elastic  fibres  and 
lung  fragments  in  the  sputum  ;  the  latter  also  exclude 
bronchiectasis.  Tuberculosis  is  excluded  by  examinations 
of  the  sputum  for  tubercle  bacilli.  When  an  empyema 
opens  into  a  bronchus  the  discharge  of  pus  is  often  followed 
by  the  signs  of  partial  pyopneumothorax,  metallic  ausculta- 
tion, percussion  phenomena,  andhippocratic  succussion. 

INDICATIONS   FOR   OPERATION. 

When  there  are  definite  signs  of  an  acute  solitary  abscess, 
or  of  several  abscesses  situated  close  together  in  one  lobe, 
operation  should  be  undertaken  without  delay,  unless 
there  are  signs  of  spontaneous  healing.  The  condition 
should  not  be  allowed  to  become  chronic  (Quincke).  If 
spontaneous  recovery  occurs  the  process  takes  from  three 
to  ten  weeks,  and  will  be  indicated  by  decrease  in  the 
discharge  of  purulent  sputum  and  decline  of  the  fever. 
In  one  of  my  own  cases  it  was  decided  to  forego  operation  on 
account  of  the  diminution  in  the  amount  of  sputum,  and 
spontaneous  recovery  took  place  in  the  course  of  a  few 
weeks.  An  exact  localization  is  an  essential  preliminary 
to  operation,  and  it  must  also  be  definitely  ascertained  that 
there  is  only  one  abscess,  and  that  it  is  not  of  very  small 
size.  When  the  general  symptoms  are  of  a  severe  type, 
with  high  fever  and  abundant  expectoration  of  pus  and 
lung  debris,  and  when  physical  examination  shows  a  definite 
local  area  of  infiltration  in  the  lower  lobe,  pneumotomy  is 
justifiable,  even  in  the  absence  of  signs  of  cavity,  when 
the  patch  of  dullness  is  surrounded  by  normal  lung  tissue. 
Foci  in  the  lower  lobe  behind  are  the  most  favourably 
situated  for  operation  ;  signs  of  pleural  adhesions  will 
make  one  recommend  operation  the  more  readily.  Chronic 
abscesses,  with  copious  and  particularly  with  putrid  secretion, 
should  be  operated  on  by  resection  of  several  ribs,  free 
opening  of  the  cavity  and,  if  necessary,  partial  excision 
of  the  abscess  wall. 

In  abscesses  due  to  the  presence  of  foreign  bodies, 
pneumotomy  is  only  indicated  when  the  foreign  body 
cannot  be  extracted  by  the  respiratory  channels,  when 
the  discharge  of  pus  is  copious,  and  the  signs  of  general 
flisturbance    are    serious      Puncture,  without    opening   the 


io8  INDICATIONS    FOR    OPERATION    IN 

thoracic  cavity,  is  a  most  dangerous  proceeding,  and  should 
never  be  done. 

Contra-indications. — No  operation  should  be  done  when 
there  is  reason  to  believe  that  there  are  multiple  abscesses 
present,  and  this  is  particularly  to  be  expected  in  pysemia, 
puerperal  sepsis,  and  influenza-pneumonia.  Operation  is 
also  contra-indicated  when  there  are  no  local  signs  of  cavity 
with  moderate  fever,  and  no  alarming  symptoms  of  general 
disturbance  ;  often  in  such  cases  eventual  recovery  takes 
place  by  discharge  of  the  pus  through  the  bronchi.  With 
few  exceptions,  which  have  already  been  alluded  to,  abscesses 
due  to  foreign  bodies  are  not  suitable  for  thoracotomy. 

Prognosis. — Of  operation. — In  acute  cases  statistics  show 
recovery  after  operation  in  73  per  cent  ;  death  in  27  per 
cent.  In  chronic  cases  the  recoveries  were  51  per  cent  ; 
23'5  per  cent  improved,  and  there  were  25'5  per  cent  of 
deaths.  In  more  than  two-thirds  of  the  acute  cases, 
therefore,  operation  cured  ;  in  cases  complicated  by 
gangrene  the  prognosis  is  much  worse.  The  prognosis  is 
less  favourable  in  chronic  cases,  particularly  when  the 
discharge  is  foetid  ;  thoracic  fistulae  often  persist.  The 
advantages  of  pleural  adhesions,  from  the  point  of  view 
of  operation,  have  been  already  mentioned. 

//  no  operation  he  done  the  abscess  may  extend,  empyema 
or  pyopneumothorax  may  develop,  or  general  septic 
infection  mav  supervene  and  cause  death.  An  acute 
abscess  often  becomes  chronic,  and  the  strength  may  be 
exhausted  by  constant  and  long-continued  discharge. 
On  the  other  hand,  many  pulmonary  abscesses  disappear 
spontaneously  by  evacuation  through  the  respiratory 
channels.     (See  "  Indications.") 

LITERATURE. 

ScHULz.  Ueber  den  Lungenabscess  und  seine  chirurg.  Behand- 
lung.  Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  No.  i  und  ff. 
1901. 

Quincke.  Ueber  Pneumotomie.  Mitteil.  a.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     Bd.  i,  H.  2. 

TuFFiER.     Chirurgie    du    Poumon.     Paris,    1897. 

AuFRECHT.  Lungenentzundungen.  Nothnagel's  Handbuch  d. 
spez.  Pathol. 

Quincke.  Chirurg.  Behandlung  der  Lungenkrankh.  Mitteil.  a.  d. 
Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ix.,  H.  3. 

Garre.   Lenhartz.     Ibid. 


DISEASES   OF   THE  BRONCHI   AND    THE  LUNGS.     109 

PULMONARY    TUBERCULOSIS. 

There  is  no  need  to  describe  here  the  etiology  and 
chnical  course  of  this  affection.  The  indications  for 
surgical  interference  have  not  yet  been  settled  with  sufficient 
precision  to  allow  one  to  formulate  any  exact  rules.  Many 
cases  have  been  submitted  to  operation,  but  these  have 
been  of  such  diverse  types,  and  the  methods  of  operation 
have  varied  to  such  an  extent,  that  the  records  do  not 
furnish  material  for  forming  any  precise  opinions  on  the 
question. 

The  subject  has  been  recently  discussed  by  Quincke, 
who  has  devoted  so  much  attention  to  lung  surgery,  and 
by  Garre.  According  to  these  authors  the  indications 
for  operation  are  as  follows  :  only  when  the  patient's 
general  health  is  still  good,  and  when  he  presents  a  single 
^circumscribed  focus  of  disease,  is  operation  to  be  thought  of. 
In  such  a  case,  when  there  are  signs  of  retention  and  decom- 
position of  secretion,  and  symptoms  of  septic  absorption, 
the  cavity  should  be  freely  opened  and  drained.  In  the 
rare  cases  of  isolated  cavity  and  tubercular  focus  in  the 
lower  lobe,  the  infiltrated  lung  tissue  should  be  resected, 
followed  by  thoracoplasty.  In  stationary  isolated  cavities 
of  the  apex,  the  thoracic  wall  should  be  mobilized  by 
resection  of  the  first  three  ribs,  without  opening  the  pleura 
(Garre). 

Quincke  has  further  expressed  his  views  as  follows  : 
When  one  can  say  with  some  degree  of  certainty  that, 
apart  from  the  question  of  cavity,  the  tubercular  process 
in  an  advanced  stage  is  confined  to  one  upper  lobe,  present 
experience  indicates  that  mobilization  of  the  corresponding 
thoracic  wall  by  thoracoplasty  is  a  justifiable  proceeding, 
and  that  when  combined  with  other  treatment  encapsulation 
and  healing  of  the  focus  may  be  brought  about  thereby. 

The  chief  difficulty  lies  in  the  fact  that  cases  of  definitely 
circumscribed  pulmonary  tubercle  are  only  rarely  met  with, 
and  such  alone  are  suitable  for  operation  ;  in  most  cases  it 
is  difficult  to  be  certain  that  the  disease  is  really  strictly 
limited.  In  opening  cavities  there  is  a  danger  of  setting 
up  a  gangrenous  process  ;  there  is  also  the  risk  that  a 
permanent  thoracic  fistula  may  result,  or  that  healthy  lung 
tissue  may  be;  infected  by  the  contents  of  the  cavity. 


no  INDICATIONS    FOR    OPERATION    IN 

LITERATURE. 

Quincke.  Ueber  die  chirurg.  Behandlung  der  Lungenkrankh. 
]\Iitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ix.,  H.  3. 

Garre.     Ibid. 

C.  Cornet.  Die  Tuberkulose.  Nothnagel's  Handbuch  d.  spez. 
Pathol.     Wien,  1900.     Bd.  xix.,  2  Halfte,  2  Abteil. 

Berliner.  Die  operative  Behandlung  der  Lungentuberkulose. 
Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1901. 


HYDATID    CYST    OF    THE    LUNG. 

Pathological  Anatomy. ^As  a  rule  there  is  a  single 
cyst  in  one  of  the  lower  lobes,  most  frequently  the  right, 
and  the  cyst  is  almost  always  unilocular.  It  may  reach 
the  dimensions  of  an  infant's  head,  and  not  infrequently 
ruptures  into  a  bronchus  or  into  the  pleural  cavity.  Some- 
times suppuration  occurs  in  the  cyst,  and  even  calcification. 
When  suppuration  supervenes  there  are  usually  inflam- 
matory changes  in  the  surrounding  parts,  infiltration, 
empyema,  and  occasionally  gangrene. 

Clinical  Signs. — Occasionally  there  are  no  symptoms. 
Very  often  there  is  very  troublesome  cough,  sometimes 
associated  with  haemoptysis  and  attacks  of  dyspnoea. 
When  there  is  dullness  to  percussion  it  often  presents  a 
characteristic  vaulted  outline  ;  as  a  rule  rales  are  absent. 
Over  the  dull  area  breath  sounds  are  usually  absent,  or 
there  may  be  indistinct  bronchial  breathing.  The  neigh- 
bouring organs  are  often  dislocated.  If  suppuration  occurs 
and  the  pus  is  discharged  into  a  bronchus,  signs  of  cavity 
may  appear.  Suppuration  is  of  course  associated  with  fever. 
Particles  of  membrane  and  vesicles  are  comparatively 
frequently  coughed  up. 

Diagnosis. — The  diagnosis  is  not  usually  made  until 
membranous  particles  or  vesicles  are  coughed  up,  or  fluid 
containing  scolices  is  found  by  exploratory  puncture.  If 
fluid  obtained  by  puncture  is  limpid,  free  from  albumin  but 
rich  in  sodium  chloride,  there  can  hardly  be  any  doubt  that 
the  condition  is  one  of  hydatid  cyst.  If  pus  is  drawn  off, 
the  discovery  of  booklets  in  it  will  show  the  nature  of  the 
case.  Signs  of  hydatid  elsewhere  will  aid  early  diagnosis, 
when  there  is  a  patch  of  lung  dullness  with  absence  of  breath 
sounds  and  displacement  of  neighbouring  organs. 


DISEASES   OF   THE  BRONCHI  AND    THE  LUNGS,     in 

Differential  diagnosis. — The  signs  just  mentioned  will  be 
sufficient  to  distinguish  hydatid  cyst  from  pleurisy  with 
effusion,  interlobar  pleurisy,  chronic  pneumonia,  and  similar 
affections. 

INDICATIONS   FOR   OPERATION. 

If  the  diagnosis  is  certain  and  the  position  of  the  cyst 
ascertained,  it  should  be  opened  through  the  pleura  and 
lung  unless  it  is  very  deeply  situated.  The  absence  of 
pleural  adhesions  fixing  the  lung  is  no  absolute  bar  to 
operation.  If  suppuration  has  set  in,  operation  should  be 
done  with  the  least  possible  delay. 

Contra-indications. — When  a  skiagram  shows  the  cyst  to 
be  close  to  the  hilum,  operation  is  inadvisable.  With  this 
exception  there  are  no  contra-indications,  provided  that 
the  general  condition  of  the  patient  has  not  been  allowed 
to  become  very  bad. 

Prognosis. — Results  and  risks  of  operation. — In  many 
cases  a  complete  cure  has  been  obtained,  in  others  a 
thoracic  fistula  persists.  The  risks  of  operation  are  at 
present  considerable.  In  one  of  my  cases  where  the  cyst 
had  suppurated  and  where  it  was  only  possible  to  make  a 
simple  incision,  death  followed  in  a  month  from  waxy 
disease  due  to  the  chronic  discharge. 

//  no  operation  he  done  the  prospect  is  that  the  cyst  will 
grow,  eventually  become  infected  and  cause  death  from 
exhaustion.  Without  operation  about  60  per  cent  of  the 
cases  die. 

LITERATURE. 

Mosler-Peiper.  Die  tierischen  Parasiten.  Nothnagel's  Handbuch 
d.  spez.  Pathol.     Wien,  1894. 

Neisser.     Die  Echinococcenkrankheit.     Berlin,  1877. 

Lenhartz.  Handbuch  der  prakt.  Medizin.  Ebstein-Schwalbe 
Bd.  i.     Stuttgart. 

ACTINOMYCOSIS    OF    THE    LUNG. 

Etiology. — -Pulmonary  actinomycosis  usually  results 
from  the  aspiration  of  infected  barley  grains  into  the  bronchi. 
More  rarely  it  is  secondary  to  actinomycosis  of  the  mouth. 

Pathological  Anatomy. — At  the  site  of  the  disease 
the  lung  is  usually  collapsed,  thickened,  and  infiltrated 
witli  dense  connective  tissue,  and  often  interspersed  with 


112  INDICATIONS    FOR    OPERATION    IN 

small  pus-containing  cavities.  As  the  disease  progresses 
the  pleura  is  greatly  thickened  and  adherent,  and  the  skin 
becomes  of  a  board-like  hardness  from  infiltration.  The 
skin,  pleura,  and  lung  are  often  riddled  with  fistulous 
tracts.  When  the  disease  is  extensive  there  is  much 
sclerosis  and  shrinking  of  the  lung. 

Clinical  Course. — In  typical  cases  three  stages  may  be 
distinguished  (Israel).  First  there  is  bronchial  catarrh, 
followed  by  signs  of  interstitial  infiltration  of  a  lower 
lobe  and  the  formation  of  cavities  and  general  s^^mptoms 
resembling  those  of  tuberculosis,  fever,  loss  of  flesh,  pallor, 
and  sweating.  In  the  second  stage  there  are  pleural  signs, 
adhesions,  etc.,  and  retraction  of  the  thoracic  wall  is  often 
to  be  noted.  In  the  third  stage  the  skin  becomes  involved 
and  suppurates,  with  the  formation  of  multiple  sinuses. 
In  the  pus  the  characteristic  golden  yellow  granules 
are  to  be  seen,  and  in  the  sputum  often  elastic  fibres  in 
addition. 

Diagnosis  and  Differential  Diagnosis. — The  condition 
may  easily  be  confounded  with  tuberculosis  ;  the  absence 
of  tubercle  bacilli  and  the  presence  of  the  actinomycotic 
grains  are  the  only  signs  by  which  the  distinction  can  be 
made. 

INDICATIONS    FOR   OPERATION. 

Actinomycosis  of  the  thoracic  wall  over  an  infiltrated 
lung  warrants  operation  ;  sinuses  often  lead  directly  from 
the  skin  into  the  lung  disease.  Some  surgeons  hold  the 
view  that  operation  should  not  be  done  unless  septic 
infection  of  the  skin  supervenes. 

Contra-indications. — When  the  general  condition  is  bad 
and  the  lung  disease  very  extensive,  no  operation  will  be 
recommended. 

Prognosis. — Of  operation. — Complete  success  is  rarely 
obtained  ;  usually  the  lung  disease  has  advanced  too  far  by 
the  time  its  nature  is  revealed  by  involvement  of  the  skin. 
Occasionally  the  whole  area  of  disease  has  been  successfully 
removed,  but  usually  its  extent  is  so  great  that  this  is 
impossible,  and  only  partial  excision  can  be  done. 

Without  operation  recovery  may  be  anticipated  under 
expectant  treatment  in  a  fair  number  of  cases,  but  in  the 
great  majority  the  disease  proves  fatal. 


DISEASES  OF  THE  BRONCHI  AND   THE  LUNGS.     113 

LITERATURE. 

Illich.      Klinik  der  Aktinomykose.     Wien,    1892. 

ScHLANGE.  Prognose  der  Aktinomykose.  Arch.  f.  klin.  Chir. 
1892. 

Israel.  Klin.  Beitr.  zur  Kenntnis  der  Aktinomykose  des 
Menschen.     Berlin,   1885. 

KoRANYi.  Aktinomykose.  Nothnagel's  Handbuch  d.  spez.  Pathol, 
u.  Therap.     Bd.  v.,    i   Halfte.     Wien,    1897. 

NossAL.  Die  Lungenaktinomykose.  Zentralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chir.      1902. 

Karewsky.  Beitr.  z.  Lehre  von  der  Aktinomykose  der  Lunge. 
Berl.  klin.  Wochens.   1898,   15^17. 


CHAPTER    VII. 
Diseases    of    the    Pleura. 


117 


Chapter    VII. 
DISEASES     OF     THE      PLEURA. 

PLEURISY   AND    EMPYEMA. 

Etiology. — In  a  certain  number  of  cases  pleurisy  is  a 
primary  affection,  and  in  the  majority  of  these  the  disease 
is  of  tubercular  nature.  In  a  second  group  of  cases  pleurisy 
is  secondary  to  disease  of  adjacent  organs,  and  to  this  class 
belong  the  para-  and  metapneumonic  pleurisies,  pleurisy 
following  abscess,  gangrene,  infarct,  and  tumours  of  the 
lung,  bronchiectasis,  and  mediastinal  affections,  and  those 
secondary  to  disease  in  the  abdomen,  subphrenic  abscess, 
peritonitis,  malignant  growths  of  the  intestine  and  stomach, 
affections  of  the  liver.  In  a  third  group  the  disease  is  of  a 
metastatic  type  occurring  in  the  course  of,  or  following, 
some  general  infective  process,  puerperal  sepsis,  the  acute 
exanthemata,  erysipelas,  diphtheria,  acute  rheumatism. 
Lastly,  it  may  occur  in  association  with  some  general 
dyscrasia,  gout,  scorbutus,  morbus  maculosus,  renal  disease. 
In  serous  pleurisy  the  common  pyogenic  organisms  are 
usually  found,  tubercle  bacilli  only  occasionally.  In  meta- 
pneumonic cases  the  Diplococcus  Fraenkel-W eichselhauni 
is  the  usual  organism.  In  empyemata  the  pyogenic 
organisms,  and  particularly  streptococci,  are  found. 

Pathological  Anatomy. — In  both  the  dry  and  the 
exudative  form  the  pleura  becomes  covered  with  membrane 
when  the  affection  has  been  present  for  a  long  time.  The 
effusion  may  be  serous,  purulent,  hsemorrhagic,  putrid,  or 
chylous  ;  unless  there  are  limiting  adhesions  it  occupies  the 
lowest  part  of  the  pleural  space.  As  the  exudate  is  absorbed, 
adhesions  may  shut  off  separate  fluid-containing  spaces. 
When  the  inflammatory  changes  are  intense,  dense  adhesions 
may  form  between  lung  and  chest  wall,  and  cause  retraction 
of  tlic  latter. 


ii8  INDICATIONS    FOR    OPERATION    IN 

Clinical  Course. — The  early  symptoms  of  pleurisy  are 
often  very  slight,  and  even  large  effusions  may  form  un- 
recognized ;  this  is  especially  true  of  the  tubercular  type. 
Usually  there  is  pain  in  the  side,  immobility  of  the  affected 
half  of  the  chest,  and  cough  ;  but  when  effusion  is  encysted 
there  is  often  no  cough.  Fever  may  be  absent  ;  when  it 
develops  it  indicates  an  extension  of  the  inflammatory 
process  ;  when  the  latter  becomes  stationary  the  fever 
usually  intermits,  and  when  the  exudation  is  becoming 
absorbed  the  temperature  returns  to  the  normal.  If  the 
onset  is  attended  by  rigor,  it  suggests  a  complicating  pneu- 
monia, or  that  the  disease  is  embolic  or  septic  in  character. 
When  the  effusion  is  large  the  tension  of  the  pulse  falls,  and 
diuresis  diminishes.  Friction  is  heard  at  the  beginning,  and 
towards  the  end  when  there  is  effusion  ;  and  from  the  time 
of  the  appearance  of  the  latter,  percussion  dullness  can  be 
made  out,  and  the  affected  side  of  the  thorax  bulges  and 
becomes  more  or  less  immobile.  The  outline  of  the  limits 
of  the  effusion  will  vary  somewhat  according  to  the  attitude 
adopted  by  the  patient. 

When  the  amount  of  exudation  is  large  the  neighbouring 
organs  are  displaced.  When  it  is  on  the  left  side  there  is 
dullness  in  Traube's  semilunar  space.  One  of  the  most 
important  signs  is  the  unilateral  enlargement  of  the  thorax, 
though  it  must  be  remembered  that  normally  the  left  side 
is  ^  to  1^  cm.  smaller  than  the  right.  Sometimes  there  are 
attacks  of  syncope  and  collapse,  but  sudden  death  is  rare. 

When,  in  a  patient  who  has  had  pleurisy,  an  area  of 
dullness  is  present  with  an  irregular  outline,  and  when  in 
this  area  the  other  physical  signs  of  fluid  are  also  found,  a 
diagnosis  of  encysted  exudation  is  indicated.  When  the 
lung  is  adherent  to  the  chest  wall,  breath  sounds  will  be 
audible  at  the  point  of  adhesion.  It  can  only  be  certain 
that  there  is  more  than  one  separate  collection  when  the 
exploring  needle  obtains  fluid  of  different  character  at 
different  points,  or  when,  after  complete  evacuation  with 
the  aspirator,  more  fluid  is  obtained  from  some  other  spot. 
The  exploring  needle  should  be  used  in  all  cases  of  pleurisy 
with  effusion,  for  the  purpose  of  discovering  the  exact 
character  of  the  fluid.  An  empyema  spontaneously  dis- 
charges through  the  chest  wall  only  when  it  is  associated 
with  some  acute  septic  or  gangrenous  process  ;   occasionally 


DISEASES    OF    THE    PLEURA.  119 

empyemata  are  pulsatile.  When  an  empyema  discharges 
through  the  lung  the  patient  coughs  up  very  large  quantities 
of  pus,  and  signs  of  pyopneumothorax  appear.  Meta- 
pneumonic empyemata  often  heal  spontaneously  by  this 
evacuation  through  the  respiratory  channels. 

Differential  Diagnosis. — In  pneumonia  the  fever  is 
higher  and  more  sustained ,  the  chest  wall  on  the  affected  side 
is  not  bulged,  the  intercostal  spaces  move  with  respiration, 
and  the  other  known  physical  signs  of  pneumonia  are  present. 
Sometimes  there  is  difficulty  in  distinguishing  between 
bronchiectasis  and  empyema  ;  when  repeated  examination 
gives  variable  results  in  the  physical  signs,  bronchiectasis 
is  the  more  probable.  New  growths  involving  the  pleura  are 
associated  with  very  severe  general  symptoms  :  the  supra- 
clavicular glands  are  usually  enlarged,  the  area  of  dullness 
is  irregular,  the  exudate  is  often  haemorrhagic,  and  when 
the  exploring  needle  is  used  there  is  a  sensation  of  passing 
it  through  a  hard  mass.  In  subphrenic  abscess  the 
diaphragm  is  pushed  upwards  in  a  dome-shaped  manner 
usually  on  both  sides,  and  there  are  also  signs  pointing 
to  abdominal  disease  and  peritonitis.  Hydro  thorax  is 
apyrexic,  often  bilateral,  and  there  is  no  friction,  while 
there  will  be  present  other  signs  of  circulatory  disturbance. 

INDICATIONS   FOR   OPERATION. 

The  different  operative  procedures  must  be  discussed 
separately. 

I.  Paracentesis  Thoracis  is  absolutely  indicated  in 
serous  effusions  under  the  following  circumstances  : — 

{a).  When  the  effusion  is  endangering  life  ;  dangerous 
symptoms  are — continuous  or  intermittent  severe  orthopnoea, 
attacks  of  syncope,  a  small  pulse,  cyanosis  of  the  skin  and 
mucous  membranes,  marked  engorgements  of  the  veins  of 
the  neck,  extreme  displacement  of  the  neighbouring  organs, 
particularly  the  heart  ;  these  symptoms  occur  when  the 
effusion  is  very  large  in  amount,  and  provide  an  indication 
for  thoracocentesis  without  delay. 

[h).  When  other  methods  are  attended  with  unsatisfactory 
results.  If  an  effusion  persists  for  several  weeks,  and  is  not 
fiiminislied  by  expectant  treatment  with  drugs,  etc.,  it  should 
be  drawn  off.  It  will  depend  upon  the  amount  of  the 
effusion  how  early  aspiration  will  be  indicated.     As  a  rule 


I20  INDICATIONS    FOR    OPERATION    IN 

it  will  not  be  called  for  before  the  third  week,  and  it  should 
not  be  done  whilst  fever  due  to  the  pleurisy  persists,  unless 
there  is  some  exceptional  reason  for  resorting  to  it  early  ; 
however,  even  if  fever  continues,  aspiration  should  not  be 
put  off  if  the  effusion  is  progressive,  or  remains  stationary  ; 
sometimes  it  has  to  be  repeated.  The  best  results  are 
obtained  when  fever  is  absent,  or  at  least  declining,  and 
when  the  effusion  is  stationary,  and  the  urinary  secretion 
small.  This  is  true  for  tubercular  pleuritic  cases,  as  well 
as  for  others. 

(c).  When  the  distress  of  the  patient  is  intolerable  ;  this  is 
especiall}^  the  case  in  patients  who  have  an  associated  lung 
disease,  tuberculosis,  neoplasm,  etc. 

In  hsemorrhagic  effusions  the  indications  under  the 
headings  n.  and  c.  are  alone  pertinent.  In  a  case  of  endo- 
thelioma pleurte  under  my  care  I  practised  thoracocentesis 
almost  weekly  for  several  months,  the  effusion  constantly 
threatening  death. 

Chylous  effusion  should,  as  far  as  possible,  only  be  drawn 
off  when  the  fluid  has  ceased  to  increase  in  amount,  and 
has  been  stationary  for  several  weeks. 

Contra-indications  to  Paracentesis.— K  sustained  tempera- 
ture is  a  contra-indication  during  the  first  three  weeks  unless 
there  is  danger  to  life,  and  this  operation  is  also  inadvisable 
when  the  effusion  is  hgemorrhagic  or  chylous,  unless  it  is 
very  large  in  amount  and  producing  serious  symptoms. 
If  the  fluid  be  removed  under  these  circumstances  it  will 
rapidly  reaccumulate,  and  the  operation  will  have  to  be 
repeated.  In  cases  of  serous  effusion  following  pneumo- 
thorax, in  which  the  air  has  been  reabsorbed,  and  also  in 
cases  of  effusion  after  hgemorrhagic  infarct  of  the  lung, 
it  is  wise  not  to  remove  the  whole  of  the  fluid,  and  not  to 
aspirate  with  high  suction  pressure,  because  the  visceral 
pleura  is  exceptionally  friable  in  these  conditions  (Gerhardt). 

Risks  and  accidents  of  Thoracocentesis. — With  patients 
who  are  seriously  ill  sudden  death  may  follow  aspiration, 
especially  when  large  quantities  of  fluid  (over  1500  cc.) 
are  removed  at  one  time.  Such  deaths  occur  from 
thrombosis  of  the  pulmonary  veins  and  embolus  ;  some 
are  due  to  cerebral  anaemia.  In  exceptional  cases  death 
occurs  from  haemorrhage  into  the  pleural  cavity,  or  injury 
to  the  lung.     Pneumothorax  is  a  comparatively  frequent 


DISEASES    OF     THE    PLEURA.  121 

occurrence  after  aspiration,  and  is  very  often  overlooked  ; 
as  a  rule,  in  my  experience,  it  disappears  in  the  course  of 
three  or  four  days  without  causing  any  alarming  symptoms. 

Sometimes  after  paracentesis  there  is  expectoration  of 
clear  fluid,  rich  in  albumin,  in  large  quantities  ;  this  usually 
ceases  after  a  few  hours.  The  formation  of  a  fistula  through 
the  puncture  is  very  unusual ;  when  aseptic  precautions 
are  taken  the  conversion  of  serous  into  purulent  effusion 
need  not  be  feared. 

Results  of  Paracentesis. — The  dyspnoea  diminishes,  the 
displaced  organs  regain  their  normal  situations  unless 
adhesions  have  formed,  the  pulse  becomes  fuller  and  slower, 
diuresis  increases,  and  the  bulging  of  the  thorax  dis- 
appears. In  many  cases  the  effusion  is  finally  cured  by  the 
operation. 

Paracentesis  in  Empyema. — This  should  only  be  employed 
when  it  can  be  combined  with  continuous  aspiration- 
drainage  after  the  method  of  Biilau  ;  but  this  method  is 
rarely  employed  now.  Exceptionally,  it  is  indicated  as  a 
preliminary  to  thoracotomy  when  the  symptoms  call  for 
urgent  relief. 

2.  Thoracotomy. — This  operation  is  indicated  : 

{a).  When  the  effusion  is  purulent,  provided  that  the 
patient's  general  condition  is  sufficiently  good.  It  should 
be  done  as  soon  as  the  purulent  nature  of  the  fluid  is  recog- 
nized, except,  perhaps,  in  the  metapneumonic  empyemata 
of  children  ;  according  to  Gerhardt  it  is  not  uncommon  in 
the  latter  cases  for  spontaneous  recovery  to  take  place  by 
rupture  of  the  fluid  into  the  respiratory  passages  ;  in  no 
case,  however,  should  one  delay  more  than  three  weeks. 

In  a  case  quite  recently  under  my  charge  there  was  a 
patch  of  pneumonia  centrally  localized  in  the  right  upper 
lobe.  The  temperature  remained  high,  and  there  gradually 
developed  a  narrow  band  of  dullness  approximately  parallel 
with  the  lower  border  of  the  lung  ;  below  this  dull  area 
breath  sounds  were  normal.  A  leucocytosis  was  present. 
A  diagnosis  of  interlobar  empyema  was  made,  and  the 
exploring  needle  drew  off  pus.  Operation  (Lotheissen) 
was  immediately  undertaken,  and  a  large  empyema  was 
found,  situated  partly  between  the  upper  and  middle  lobes 
and  partly  in  front  of  the  middle  lobe,  connected  with  an 
abscess  in  the  lung. 


122  INDICATIONS    FOR    OPERATION    IN 

(b).  When  the  effusion  is  putrid. 

(c).  In  cases  of  long-standing  pyopneumothorax. 

Contra-indications  to  Thoracotomy. — The  operation  should 
not  be  entertained  when  acute  phthisis  coexists,  it  will 
only  hasten  the  end.  A  very  low  vitality  and  signs  of 
heart  failure  are  against  operation,  although  cases  almost 
moribund  are  sometimes  rescued.  Serious  complications 
in  other  organs  also  contra-indicate  it.  With  regard  to  the 
relatively  rare  double  empyema  opinions  are  divided. 
Unverricht  considers  that  in  these  cases  the  fluid  is  always 
encysted,  and  can,  therefore,  be  dealt  with  by  double 
thoracotomy.  Chronic  pulmonary  tubercle  is  no  bar  to 
operation  unless  it  is  very  extensive. 

Risks. — The  dangers,  during  and  after  thoracotomy,  with 
rib  resection,  are  in  the  first  instance  dependent  on  the 
disease  itself  for  which  the  operation  is  done.  When  the 
case  is  complicated  by  severe  pulmonary  disease,  such  as 
tuberculosis  or  gangrene,  the  risks  are  relatively  great. 
Thoracotomy  without  rib  resection  is  attended  by  many 
dangers,  and  has  been,  for  that  reason,  almost  entirely 
abandoned. 

Prognosis.  —  Results  of  operation.  —  In  many  cases, 
especially  in  young  patients,  complete  recovery  follows. 
The  prognosis  is  very  good  in  young  subjects  whose  general 
condition  is  well  maintained  ;  the  great  majority  recover 
(at  least  four-fifths)  after  a  comparatively  short  conval- 
escence, if  the  operation  is  done  in  good  time. 

Prognosis  without  operation. — In  cases  of  serous  pleurisy 
the  effusion  may  organize  ;  in  some  cases  bronchiectasis 
results,  and  the  thorax  may  be  retracted  on  the  affected 
side.  Purulent  effusion  is  very  rarely  spontaneously 
absorbed ;  with  the  exception  of  the  metapneumonic 
collections,  empyemata  rarely  discharge  into  the  lung  or 
to  the  exterior,  and  should  this  take  place  high  continued 
fever  usually  results,  and  enfeebles  the  patient  ;  sometimes 
metastatic  abscesses  are  formed. 

When  the  exudate  is  putrid  it  often  causes  death,  with 
symptoms  of  septicaemia.  If  a  purulent  exudation  makes 
its  way  to  the  exterior,  fistulae  form,  and  discharge  persists 
for  a  long  time  ;  under  such  conditions  waxy  disease 
of  the  internal  organs  commonly  supervenes. 


DISEASES    OF    THE    PLEURA.  123 

LITERATURE. 

Gerhardt.     Die  Pleuraerkrankungen.     F.  Enke.      1892. 

Unv^erricht.  Die  Krankheiten  der  Pleura.  Handbuch  der  prakt. 
Med.  von  Ebstein-Schwalbe.      1899.     Bd.  i. 

RosENBACH.  Die  Pleuraerkrankungen.  Nothnagel's  Handbuch  d. 
spez.  Pathol.     Wien. 

Bahrgebuhr.  Chylose  Ergiisse  in  serosen  Hohlen.  Deut. 
Arch.  f.  klin.  Med.     Bd.  civ. 

Kummel.  Handbuch  der  prakt.  Chir.  von  Bergmann.  Bruns,  u. 
Mikulicz.      Stuttgart,    1900. 

Schede.  Chirurgie  der  Pleura.  Handbuch  der  spez.  Therap. 
von  Penzoldt-Stintzing.     Bd.   iii. 


PNEUMOTHORAX. 

Etiology. — Pneumothorax  may  result  from  a  wound 
penetrating  the  chest  wall  ;  it  also  follows  diseases  of  the 
lungs  in  which  the  pleura  is  damaged,  the  most  important 
being  tuberculosis,  gangrene,  and  abscess,  and,  among 
the  less  common,  bronchiectasis,  pulmonary  infarct, 
emphysema,  and  hydatid.  Occasionally  it  occurs  from 
disease  in  the  alimentary  tract  encroaching  on  the  pleura, 
and  may  also  be  caused  by  the  rupture  of  an  empyema  into 
the  lung. 

Pathological  Anatomy. — In  recent  cases  the  physical 
signs  are  often  very  confusing  ;  in  old-standing  cases  the 
lung  is  retracted,  the  neighbouring  organs  are  displaced, 
and  the  pleura  is  thickened  and  friable.  Pneumothorax 
is  often  total,  but  sometimes  only  partial,  when  adhesions 
prevent  its  extension.  Usually  there  is  a  patent  com- 
munication with  the  lung,  and  the  condition  is  spoken  of 
as  open  pneumothorax  ;  more  rarely  there  is  no  pulmonary 
fistula,  and  the  term  closed  pneumothorax  is  used.  In  cases 
of  long  standing  there  is  always  some  fluid  in  the  pleural 
cavity,  either  simple  or  septic  and  foetid  pus. 

Clinical  Course. — The  condition  usually  has  an  acute 
onset,  with  pain  and  intense  dyspnoea.  On  the  affected 
side,  the  chest  bulges,  and  the  intercostal  spaces  project, 
while  the  heart,  liver,  diaphragm,  and  sometimes  the  spleen, 
are  displaced.  The  percussion  note  is  hyper-resonant, 
and  a  metallic  note  (bell  sound)  is  obtained  with  the  ples- 
simeter.  The  auscultatory  sounds  also  have  a  somewhat 
metallic  rjuality,  both  the  respiratory  bruit,  and  also  those 


124  INDICATIONS    FOR    OPERATION     IN 

heard  when  the  patient  coughs  or  speaks,  but  only  excep- 
tionally is  this  noticeable  in  the  case  of  the  heart  sounds. 
The  "  tinkle  "  of  falling  drops  is  often  heard,  and  sometimes 
there  are  sounds  resembling  those  produced  in  a  "  hookah." 
An  important  phenomenon  is  the  so-called  hippocratic 
succussion,  iirst  appearing  after  the  pneumothorax  has 
been  present  for  some  days.  Sometimes,  and  in  particular 
in  traumatic  cases,  no  breath  sounds  at  all  are  audible  on 
the  affected  side.  The  fluid  present  is  free  in  the  pleural 
cavity,  and  its  limits,  as  revealed  by  percussion  dullness, 
vary  according  to  the  patient's  attitude  ;  it  occupies  what- 
ever for  the  time  being  is  the  most  dependent  part,  and  its 
upper  limit  is  horizontal.  When  there  is  a  persistent  open 
communication  with  the  lung  there  is  no  displacement  or 
retraction  of  the  heart  and  other  structures  ;  the  tympanitic 
physical  signs  are  usually  present  in  such  cases  and  not 
infrequently  a  bruit  de  pot  fele  is  also  heard.  A  pneumo- 
thorax in  a  pleural  cavity  more  or  less  obliterated  by 
adhesions,  is  partial  ;  often  under  these  circumstances 
there  is  much  deformity  from  retraction,'  but  sometimes 
this  is  wanting.  Usuall}-  succussion  can  be  elicited  when 
the  condition  is  of  long  standing.  Radiography  shows  a 
clear  zone  corresponding  to  the  pneumothoracic  space  or 
spaces. 

Diagnosis  and  Differential  Diagnosis. — If  the  phy- 
sical signs  are  well  developed  there  can  be  no  difficulty 
about  the  diagnosis.  A  partial  pneumothorax  may  be 
mistaken  for  a  cavity  in  the  lung,  but  in  the  latter  condition 
the  characteristic  tympanitic  signs  are  very  rarely  present, 
and  succussion  is  hardly  ever  found.  The  sudden  develop- 
ment of  the  symptoms,  their  localization  at  the  base,  and  the 
displacement  of  neighbouring  organs,  make  the  diagnosis 
of  pneumothorax  certain,  for  lung  cavities  of  large  size  are 
hardly  ever  present  except  in  the  upper  lobe,  are  gradual 
in  development,  and  are  not  associated  with  visceral 
displacements. 

Subphrenic  pyopneumothorax  is  often  difficult  to 
distinguish  from  pneumothorax,  but  a  history  of  primary 
abdominal  signs  pointing  to  some  suppurative  lesion  in 
the  abdomen  will  probably  be  obtainable  in  the  case  of  the 
former.  Rarely,  there  may  be  some  difficulty  in  deciding 
whether   clinical   signs   resembling  pneumothorax   are   not 


DISEASES    OF    THE    PLEURA.  125 

due    to    extreme    gastric    dilatation,    or    a    diaphragmatic 
hernia. 

INDICATIONS   FOR   OPERATION. 

Operation  is  undertaken  in  some  cases  for  the  rehef  of 
extreme  dyspnoea,  in  others  for  the  cure  of  the  condition 
itself.  If  dangerous  dyspnoea  is  present,  thoracocentesis 
is  indicated  ;  it  is  more  beneficial  to  extract  fluid  than  air 
from  the  pleural  cavity.  This  vital  indication  holds  for 
both  the  curable  and  incurable  cases.  No  general  rules 
for  thoracotomy  can  be  laid  down  ;  the  decision  will  depend 
on  the  cause  of  the  pneumothorax,  the  general  condition 
of  the  patient,  and  other  matters.  The  following  rule  of 
Gerhardt's  will,  however,  cover  many  cases:  "  Pyopneumo- 
thorax which  persists  for  several  days,  and  is  not  essentially 
incurable,  should  be  treated  by  thoracotomy."  The 
operation  is  particularly  indicated  when  the  condition  is 
secondary  to  some  acute  lung  disease,  such  as  gangrene 
and  abscess  ;  if  it  is  secondary  to  tuberculosis  of  the  lung, 
more  or  less  circumscribed,  the  operation  is  also  called  for 
when  the  patient's  strength  is  well  sustained,  when  fever 
is  absent,  and  there  are  no  signs  that  the  tubercle  is  of  the 
rapidly  progressive  type. 

Spontaneous  rupture  of  an  empyema  with  resulting 
pneumothorax  almost  always  necessitates  operation,  but 
I  have  seen  one  such  case  recover  spontaneously  after  the 
lapse  of  a  considerable  period. 

Contra-indications. — If  the  fundamental  cause  of  the 
disease  is  incurable  and  extensive,  as  in  such  conditions  as 
advanced  phthisis,  or  ulceration  and  perforation  of  an 
oesophageal  cancer,  thoracotomy  is  inadvisable  ;  it  is  also 
inadvisable  in  pneumothorax  secondary  to  infarct,  because 
in  this  condition  there  are  usually  present  serious  circulatory 
lesions.  If  it  is  suspected  that  the  pneumothorax  is  of  a 
valvular  character,  aspiration  is  contra-indicated.  Traumatic 
pneumothorax,  following  fracture  of  the  ribs,  tends  to 
right  itself  spontaneously,  and-  no  operation  should  be 
done  in  the  early  stages. 

Risks  of  operation. — Simple  paracentesis  may  be  followed 
by  extensive  cutaneous  emphysema  if  the  puncture  is  above 
the  level  of  the  fluid.  Thoracotomy,  with  washing  out,  is 
attended   with    the   same    risks    as    in   simple    empyema ; 


126  INDICATIONS    FOR    OPERATION    IN 

convulsions,  paresis,  and  other  serious  symptoms,  may 
occur  from  embolus.  In  weak  subjects  the  risks  of  general 
anaesthesia  are  to  be  considered.  Miliary  tuberculosis  may 
follow  operation  on  tubercular  cases,  and  this  has  occurred 
in  my  own  experience. 

Prognosis.  —  Without  operation.  —  Pyopneumothorax 
following  acute  pulmonary  disease  is  attended  by  risk  to 
life  from  exhaustion  and  the  other  conditions  produced  by 
chronic  suppuration.  The  prognosis  in  tubercular  cases  is 
very  unfavourable,  according  to  West.  When  pneumothorax 
supervenes  on  pulmonary  tubercle  death  occurs  in  90  per 
cent  of  the  cases  within  a  month. 

Prognosis  of  operation. — Thoracotomy  is  often  curative 
when  the  causal  condition  of  the  pneumothorax  is  some 
acute  destructive  pulmonary  lesion.  In  other  conditions, 
where  the  lung  lesion  is  of  more  serious  and  obstinate  type, 
death  often  occurs  in  spite  of  operation  from  chronic 
suppuration  or  some  complication.  In  Schede's  words, 
"  the  prognosis  of  the  operation  for  empyema  depends 
directly  upon  the  prognosis  of  the  affection  to  which  the 
empyema  is  due.'" 

LITERx\TURE. 

Gerhardt.     Die  Pleuraerkrankungen.     Stuttgart:   F.  Enke,  1892. 

Unverricht.  Pneumothorax.  Handbuch  der  prakt.  Med.  von 
Ebstein-Schwalbe,    1900.     Bd.  i. 

SxiNTZiNG  und  ScHEDE.  Pneumothorax.  Handbuch  d.  Therap. 
innerer  Krankheiten  (Penzoldt-Stintzing),  iii. 

Baumler.  Die  Behandlung  der  Pleura-Empyema  bei  Lungen- 
tuberkulosen.     Deut.   med.  Wochens.      1894.     Nos.   ^y  and  38. 


HYDROTHORAX. 

Etiology. — Hydrothorax  is  caused  by  the  conditions 
which  produce  general  anasarca  ;  it  occurs  as  part  of  the 
general  oedema  associated  with  cardiac  and  pulmonary 
disease,  or  it  may  be  due  to  the  local  effect  of  mediastinal 
growths,  or  to  a  condition  of  hydraemia. 

Pathological  Anatomy. — Either  one  or  both  pleural 
cavities  contain  a  slightly  albuminous  fluid,  but  there  are 
no  signs  of  pleural  inflammation.  The  lung  is  compressed 
and  the  diaphragm  pushed  down  as  in  pleuritic  effusion. 


DISEASES    OF    THE    PLEURA.  127 

Clinical  Course. — The  physical  signs  of  fluid  are 
present,  but  there  are  no  signs  of  an  inflammatory  process, 
nor,  usually,  are  neighbouring  organs  displaced.  The  area 
of  dullness  is  largely  dependent  on  the  attitude  of  the 
patient  ;  the  fluid  of  transudation  is  apparently  more 
mobile  than  the  fluid  of  exudation,  and  its  specific  gravity 
is  below  1014.  Relatively  frequently  in  organic  heart 
failure  and  heart  disease  there  is  an  effusion  on  the  right 
side  only,  which  progresses  slowly  and  is  very  rebellious  to 
internal  medical  treatment. 

INDICATIONS   FOR  OPERATION. 

Thoracocentesis  may  be  indicated  :  (i)  By  the  occurrence 
of  general  dropsy,  and  of  marked  embarrassment  in  the 
movements  of  the  diaphragm  and  heart,  which  occurs 
particularly  when  there  is  much  ascites.  The  operation 
may  be  performed  on  one  or  both  sides.  (2)  By  the 
persistence  of  hydro  thorax,  when  the  general  dropsy  else- 
where has  disappeared.  If  the  effusion  is  allowed  to  remain 
in  such  cases  the  heart  is  considerably  embarrassed,  and 
fresh  disturbances  of  compensation  may  develop. 

If  these  indications  recur  the  aspiration  will  be  repeated. 

Contra-indications. — It  is  inadvisable  to  rely  on  repeated 
paracentesis  without  the  administration  of  digitalis  and 
other  cardiac  remedies. 

Prognosis. — //  paracentesis  is  withheld  in  the  first  class 
of  cases  the  sufferings  of  the  patient  are  greater,  and 
death  occurs  earlier;  in  the  second  class,  fresh  compensation- 
defects  will  arise. 

Risks  of  operation. — Acute  pulmonary  oedema,  sudden 
serious  cardiac  insufficiency,  and  even  cardiac  paralysis, 
are  accidents  which  may  follow  immediately  upon  aspiration. 

Results  of  operation. — The  removal  of  a  hydrothorax  is 
often  followed  by  much  improvement  in  the  function  of  the 
circulatory  system,  and  remedies  previously  ineffective 
may  then  produce  good  results. 

LITERATURE. 

Gekhardt.     Pleurakrankheiten.     Deut.  Chir.     Stuttgart,  1892. 
KiJMMEL.     Die  Krankheiten    der    Pleura.     Handbuch  der  prakt 
Med.     Ebstein-Schwalbe.     Bd.  i. 


128  INDICATIONS    FOR    OPERATION    IN 

TUMOURS   OF    THE    PLEURA. 

Pathological  Anatomy. — Tumours  of  the  pleura  may 
be  primary  or  secondary.  The  primary  tumours  are 
endothehomata  ;  they  form  dense  and  extensive  masses, 
spreading  for  the  most  part  on  the  surface.  Secondary 
tumours  usually  co-exist  with  growths  in  the  lungs.  Usually 
there  is  effusion  in  the  pleural  cavity,  and  this  is  often 
haemorrhagic. 

Clinical  Course. — The  disease  is  often  masked  by 
extensive  effusion.  This  often  develops  rapidly  without 
fever,  and  produces  much  displacement  of  organs,  and  if 
removed  by  puncture  rapidly  collects  again.  Although 
often  haemorrhagic  it  may  not  be  so  in  its  early  stages,  as 
in  a  case  under  my  care,  in  which  blood  was  found  present 
only  after  the  fluid  had  been  drawn  off  three  times.  Par- 
ticles of  growth  may  be  found  in  the  fluid,  and  their  discovery 
has  often  led  to  a  correct  diagnosis.  Diagnosis  may  also 
be  assisted  by  enlargement  of  supraclavicular  glands, 
rapid  wasting,  and  the  persistence  of  dullness  after  puncture 
in  atypical  situations.  Expectoration  of  bright  red  sputum, 
pointing  to  growth  in  the  lung,  and  the  rapid  development 
of  implantation  growth  along  the  puncture  track  will  reveal 
the  true  nature  of  the  condition.  I  have  seen  such  implanta- 
tion metastases  in  two  cases  ;  in  one,  a  nodule  the  size  of  a 
hazel  nut  developed  within  the  short  space  of  forty-eight 
hours  after  the  aspiration. 

INDICATIONS   FOR   OPERATION. 

A  radical  operation  is  never  possible  in  the  case  of  primary 
tumours  ;  but  thoracocentesis  may  be  done  to  prolong  life. 
The  interval  between  one  aspiration  and  another  should  be 
kept  as  long  as  possible,  for  the  fluid  often  rapidly  reaccumu- 
lates  ;  and  the  drawing  off  of  the  highly  albuminous  fluid 
at  short  intervals  may  hasten  rather  than  delay  the  fatal 
termination. 

Secondary  involvement  of  the  pleura  by  growths  of  the 
thoracic  wall  is  no  contra-indication  to  operative  treatment ; 
if  there  is  very  distressing  pain,  or  symptoms  develop 
which  directly  threaten  life,  operation  is  indicated,  even  if 
metastases  are  already  present  (Amburger). 

Prognosis. — Dangers  of  operation. — The  risks  are  greater 


DISEASES    OF    THE    PLEURA.  129 

than  in  dealing  with  ordinary  pleuritic  effusions  ;  it  is  more 
frequently  followed  by  haemorrhage  into  the  pleura,  and 
collapse.  If  the  pleural  growth  is  secondary,  and  there  are 
general  metastases,  it  is,  on  the  whole,  wise  to  do  nothing. 

LITERATURE. 

Unverricht.  Krebsige  Pleuraergiisse.  Zeits.  f.  klin.  Med. 
Bd.  iv. 

V.  Weismayer.     Tumoren  der  Pleura.     Wien,    1897. 

Zagari.     Tumori  Maligni  Primari  della  Pleura.     Naples,   1896. 

RosENBACH.  Krankheiten  des  Brustfells.  Nothnagel's  Handbuch 
der  spez.  Pathol,  u.  Therap.     Bd.  xiv.,  i  Halfte. 

Amburger.  Brustwandgeschwiilste.  Beitr.  z.  klin.  Chir_ 
Bd.  XXX. 


CHAPTER    VIII. 

Diseases    of    the    Mediastinum. 


133 


Chapter  VIII. 
DISEASES   OF   THE   MEDIASTINUM. 

SUPPURATIVE    MEDIASTINITIS. 

Etiology. — Hoffmann  distinguishes  three  etiological 
types :  firstly,  mediastinitis  caused  by  the  spread  of  inflam- 
matory processes  from  neighbouring  organs  ;  secondly, 
metastatic  abscesses  ;  thirdly,  traumatic  mediastinitis. 
Tuberculosis  is  the  most  common  cause  of  purulent  collec- 
tions here,  less  frequently  the  presence  of  foreign  bodies  in 
the  oesophagus  or  new  growths  of  this  channel.  In  a 
relatively  large  number  of  cases  mediastinal  suppuration 
has  its  origin  in  the  neck  or  in  the  buccal  cavity  or  the 
vertebral  column,  and  makes  its  way  downwards  ;  occasion- 
ally it  results  from  the  extension  of  a  pulmonary  lesion  or  of 
a  subphrenic  abscess.  As  a  metastatic  process  it  is  met 
with  in  erysipelas  and  typhoid  fever.  I  have  met  with  two 
cases  in  syphilitic  subjects. 

Pathological  Anatomy. — Suppuration  appears  to  occur 
more  frequently  in  the  anterior  than  the  posterior  medias- 
tinum. Very  large  collections  may  form  and  may  make 
their  way  into  neighbouring  organs,  or  come  to  the  surface. 
As  a  rule  the  lesions  are  complex  and  affect  parts  other  than 
the  mediastinum.  The  pus  is  often  of  a  highly  septic  or 
putrid  type. 

Symptoms  and  Diagnosis. — Mediastinal  suppuration 
must  be  looked  upon  as  an  uncommon  lesion ;  it  is  almost 
always  attended  by  fever,  but  in  tubercular  cases  this  may 
be  of  very  slight  degree.  Pain,  and  particularly  throbbing 
pain,  is  usual,  but  not  always  present;  in  two  cases  of  my 
own  it  was  entirely  absent.  There  may  be  tenderness  on 
pressure  over  the  sternum,  and  the  skin  here  may  be  red 
and  fjedematous.  Sometimes  a  skiagram  shows  a  shadow 
corresponding  to  the  j)urulent  collection.     I   have  several 


134  INDICATIONS    FOR    OPERATION    IN 

times  noted  dullness  in  the  first  and  second  intercostal 
spaces.  Various  symptoms  may  arise  from  compression 
and  narrowing  of  the  mediastinal  space,  the  neighbouring 
organs  and  channels  are  all  more  or  less  affected,  but  in 
varying  degrees.  In  two  of  my  cases  the  laryngoscope 
showed  compression  of  the  trachea,  and  the  cause  of  this 
was  cleared  up  when  a  large  collection  of  pus  ruptured  into 
the  trachea,  the  mediastinal  symptoms  then  subsiding. 
Other  symptoms  that  may  be  met  with  are  paralysis  of 
the  recurrent  laryngeals,  oesophageal  symptoms,  cardiac 
embarrassment,  engorgement  of  the  cervical  veins.  In 
a  considerable  proportion  of  cases,  both  tubercular  and 
non-tubercular,  the  pus  finds  its  way  to  the  surface  through 
an  intercostal  space.  In  many  cases  the  gravity  of  the 
primary  lesion  is  such  that  death  results  ;  occasionally 
recovery  follows  discharge  of  the  pus,  or  a  chronic  lesion 
may  eventuate. 

INDICATIONS   FOR   OPERATION. 

As  soon  as  a  diagnosis  of  suppurative  mediastinitis  has 
been  made,  the  focus  should  be  opened,  provided  it  is  acces- 
sible, and  the  patient's  general  condition  admits  of  operation. 
The  diagnosis  is  most  clear  when  there  is  a  lesion  of  the  bones 
adjacent  to  the  mediastinum  (sternum,  vertebrae),  or 
when  the  presence  of  a  foreign  body  in  the  oesophagus  is 
associated  with  fever  and  signs  of  compression  of  the  medias- 
tinal organs,  but  such  indications  are  present  in  only  a 
small  proportion  of  cases.  In  most,  the  indication  leading 
to  operation  will  be  the  appearance  of  a  circumscribed 
oedema  on  some  part  of  the  thoracic  wall,  or  the  discovery 
of  an  abscess  which  has  extended  downwards,  pointing  to 
some  septic  lesion  at  a  higher  level ;  or  the  discovery  of 
carious  bone  or  of  a  foreign  body  in  the  gullet  may  lead  to 
a  true  understanding  of  the  case.  Operation  consists  in 
opening  the  mediastinum,  either  by  trephining  the  sternum 
or  by  resection  of  ribs. 

Contra-indications. — No  operation  should  be  done  if  the 
exact  situation  of  the  pus  is  not  known,  if  the  mediastinal 
abscess  is  only  one  of  many  metastatic  abscesses,  or  if  the 
suppuration  is  due  to  some  necessarily  fatal  lesion. 

Prognosis.— i^esw/i(s  of  operation. — The  results  of  operation 
are  uncertain.     In    one   case   recently    under  my  care  the 


DISEASES    OF     THE     MEDIASTINUM.  135 

immediate  result  was   good,  but  the    suppurative  process 
steadily  extended. 

LITERATURE. 

Hoffmann.  Erkrankungen  des  Mediastinums.  Nothnagel's 
Handbuch  d.  Spez.  Pathol,  u.  Therap.      1897. 

Hare.  The  Pathology,  Clinical  History,  and  Diagnosis  of 
Affections  of  the  Mediastinum.     Philad.,   1889. 

Enderlen.  Ein  Beitr.  z.  Chir.  des  hinteren  Mediastinums. 
Deut.  Zeit.  f.  Chir.     Bd.  cxi. 

HuisMANS.  Mediastinale  Erkrank.  Wiener  klin.  Rundschau, 
1901,  No.  37. 

MEDIASTINAL    TUMOURS. 

Pathological  Anatomy. — Tumours  of  the  mediastinum 
are  either  primary  or  secondary,  the  former  alone  being 
suitable  for  operative  treatment.  Primary  growths  may  be 
simple  or  malignant.  The  lymphosarcomata  are  often 
very  extensive  and  may  occupy  the  whole  mediastinal 
space  and  envelop  the  trachea  and  vessels.  The  sarcomata 
earty  infiltrate  the  trachea  or  the  bronchi.  Carcinomata 
are  usually  secondary.  The  simple  growths  are  less  common 
than  the  malignant ;  they  occur  in  the  following  order  of 
frequency  :  endothoracic  goitre,  dermoid  cyst,  fibroma, 
lipoma,  hydatid  cyst.  An  endothoracic  goitrous  tumour 
may  be  retrosternal,  and  may  compress  the  innominate  vein 
and  the  trachea,  or  it  may  lie  behind  the  clavicle  and  extend 
laterally  into  the  thorax  and  compress  the  lung  ;  often  it  is 
connected  with  the  thyroid  gland  by  a  pedicle  of  varying 
size.  Occasionally  two  such  growths  have  been  met  with, 
both  connected  with  the  thyroid  gland.  Dermoid  cysts 
are  always  situated  in  the  upper  half  of  the  anterior  medias- 
tinum, and  almost  always  extend  to  one  side  of  the  thorax 
only.  They  may  reach  large  dimensions,  usually  project 
into  the  neck  or  into  an  intercostal  space,  and  may  rupture 
into  a  bronchus  or  into  the  pericardium  or  a  large  vessel  ; 
they  often  form  adhesions  to  surrounding  structures. 

Clinical  Course. — The  symptoms  caused  by  mediastinal 
tumours  are  very  variable.  In  addition  to  the  general 
symptoms  only  produced  by  malignant  growths,  there  is  a 
whole  series  of  important  local  signs.  Dilatation  of  the 
veins  of  the  anterior  thoracic  wall  is  especially  common, 
and  is  sometimes  associated  with  oedema.     The  tumour  is 


136  INDICATIONS    FOR    OPERATION    IN 

sometimes  palpable  from  the  neck  ;  in  intrathoracic  goitre 
it  is  almost  always  possible  to  feel  a  prolongation  from 
the  thyroid  passing  downwards  behind  the  sternum  or  the 
clavicle.  Dullness  is  usually  found  in  the  first  intercostal 
space,  and  signs  of  pressure  on  the  trachea  and  bronchi 
and  the  other  mediastinal  structures,  oesophagus,  nerve 
trunks,  etc.  Glandular  swellings  in  the  neck  are  usually 
only  present  when  the  growth  is  malignant.  Pleural 
effusion  is  often  an  associated  sign  ;  even  without  this  the 
thoracic  wall  is  often  bulged,  particularly  by  dermoid 
growths.  When  a  dermoid  cyst  ruptures  into  a  bronchus, 
hair  is  coughed  up  by  the  patient,  if  it  ruptures  externally 
it  discharges  an  oily,  viscous  fluid  ;  such  a  fistula  often  heals 
and  then  breaks  down  again. 

Diagnosis. — It  is  of  the  greatest  importance  that  an 
early  diagnosis  of  simple  mediastinal  growths  should  be 
made.  They  are  distinguished  by  their  slow  development 
and  by  the  absence  of  any  sudden  onset  of  compression 
symptoms.  The  presence  of  a  goitre  in  the  neck  will  at 
once  indicate  the  nature  of  a  growth  in  the  upper  anterior 
mediastinum.  Dermoid  cysts  may  sometimes  be  diagnosed 
by  exploratory  puncture,  as  in  a  case  recently  seen  in  a  clinic 
in  Vienna  (Tiirk)  ;  in  other  cases,  the  discharge  from  a 
recently  established  fistula,  or  the  coughing  up  of  hair 
associated  with  signs  of  mediastinal  tumour  in  a  young 
individual,  has  established  the  diagnosis.  In  one  case  a 
skiagram  revealed  the  true  nature  of  such  a  tumour. 

The  greatest  difficulty  lies  in  differentiating  between 
tumours  and  aneurysm,  encapsuled  pleural  effusion,  or 
empyema.  Dermoid  cysts  may  be  actually  associated 
with  the  latter.  Sometimes  a  bronchiectasis  which  ruptures 
into  a  bronchus  may  cause  difficulty  in  diagnosis. 

INDICATIONS   FOR   OPERATION. 

If  a  simple  tumour  of  the  anterior  mediastinum  is 
definitely  diagnosed,  operation  for  its  removal  should  be 
undertaken,  unless  the  patient  is  very  weak  or  the  tumour 
is  of  very  large  dimensions.  Very  large  growths  have, 
however,  been  successfully  removed ;  for  example,  a  dermoid 
cyst  of  great  size  was  successfully  dealt  with  by  v.  Eiselberg 
and  Tiirk. 

Contra-indications. — In    cases   of    intrathoracic    goitre  or 


DISEASES     OF     THE     MEDIASTINUM.  137 

other  growths,  when  the  symptoms  are  not  urgent,  operation 
should  not  be  undertaken  until  internal  treatment  with 
thyroid  extract  has  been  tried.  In  one  case  of  a  most  severe 
type  I  have  observed  almost  complete  disappearance  of  all 
symptoms  under  this  treatment.  Antisyphilitic  treatment 
should  also  be  tried  when  there  are  such  signs  as  glandular 
swellings.  When  cachexia,  glandular  enlargement,  and 
the  presence  of  other  growths  point  to  the  malignant 
character  of  a  mediastinal  growth,  operation  would  be 
useless. 

Prognosis. — Risks  and  results  of  operation. — The  risks  of 
a  radical  operation  must  necessarily  be  great  ;  but  many 
successful  operations  on  simple  growths  have  been  recorded. 
In  many  cases  of  dermoid  cyst  where  extensive  secondary 
adhesions  have  formed,  only  incision  and  drainage  is  to  be 
recommended.  This  procedure  is  much  less  dangerous 
than  a  radical  operation,  but  less  likely  to  be  successful  in 
curing  the  condition. 

//  no  operation  he  done,  a  tumour,  although  of  simple 
character,  will  cause  death  by  its  mechanical  effects.  All 
cases  of  dermoid  cyst  left  alone  have  died  either  directly 
from  the  growth,  or  from  some  complication  (Ekehorn). 
There  are  cases,  however,  in  which  the  presence  of  the 
tumour  is  compatible  with  a  comparatively  long  life.  I  am 
acquainted  with  a  patient  who  has  had  tracheal  stenosis 
from  a  mediastinal  growth  for  seven  years,  yet  he  is  still  in 
good  condition,  and  the  large  growth  produces  relativeh' 
few  local  symptoms. 

LITERATURE. 

Hoffmann.  Krankheiten.  des  Mediastinums.  Xothnagel's 
Handbuch  d.  spez.  Pathol,  u.  Therap.     Bd.  xiii. 

WuHRMANN.  Endothorakale  Strumen.  Deut.  Zeit.  f.  Chir. 
Bd.  xciii. 

E.  Pflanz.  Dermoidcvsten  des  Mediast.  Ant.  Zeit.  f.  Heilk. 
Bd.  xvii. 

Ekehorn.  Die  Dermoidcvsten  des  Mediast.  Ant.  Arch.  f. 
klin.  Chir.     Bd.  cvi. 

GussENBAUER.  Lipom  des  Mediastinums.  Arch.  f.  kUn.  Chir. 
Bd.  xciii. 


CHAPTER     IX. 

Diseases   of  the    Heart    and    Blood-Vessels. 


141 


Chapter   IX. 
DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 

PERICARDITIS. 

Etiology. — Pericarditis  is  most  frequently  caused  by 
acute  rheumatism,  tuberculosis,  and  pleuropneumonia  ; 
next  in  order  of  frequency  come  septicsemia,  scarlatina, 
acute  periostitis,  and  the  dyscrasic  affections,  particularly 
scurvy,  hsemophilia,  carcinoma,  and  Bright's  disease.  It 
also  appears  that  a  primary  infection  of  the  pericardium  by 
way  of  the  blood  stream  may  occur,  a  form  to  which  the 
term  idiopathic  pericarditis  is  applied.  The  pericardium 
also  may  be  involved  in  contiguous  septic  processes,  bronchi- 
ectasis, pulmonary  gangrene,  subphrenic  abscess,  oesophageal 
cancer,  empyema,  mediastinitis,  etc. 

Pathological  Anatomy. — The  inflammatory  process 
may  be  adhesive  or  exudative.  Exudation  may  be  serous, 
hsemorrhagic,  purulent,  or  septic.  The  fluid  collects  earliest 
and  in  greatest  amount  about  the  great  vessels  and  in  the 
angle  between  heart  and  liver  ;  when  the  pericardium 
becomes  distended,  fluid  collects  behind  the  heart.  The 
amount  may  reach  1500  cc.  or  even  2000  cc.  The  heart 
muscle  is  usually  involved  in  the  inflammatory  process  ; 
when  healing  takes  place  the  pericardial  space  is  often  more 
or  less  obliterated. 

Clinical  Course. — The  affection  is  characterized  by  the 
appearance  of  friction  sounds  which  are  not  completely 
isochronous  with  the  heart  phases,  are  entirely  independent 
of  respiration,  and  are  increased  in  intensity  when  the 
stethoscope  is  pressed  on  the  chest  wall.  The  exudation 
first  fills  the  cardio-hepatic  angle  and  elevates  the  base  ; 
later  the  dullness  extends  to  the  left  beyond  the  apex  point, 
and  assumes  a  roughly  triangular  shape  with  a  broad  base  ; 
it  extends  as  the  condition  progresses.  To  the  left,  behind 
and  below,  the  percussion  note  is  usually  tympanitic  in  the 


142  INDICATIONS    FOR    OPERATION    IN 

early  stages  and  the  breath  sounds  are  indistinct.  Very  often 
a  pleuritic  inflammation  is  associated  with  the  pericarditis. 
The  veins  of  the  neck  are  usually  distended  ;  fever  is  usual, 
but  not  constant ;  when  the  exudate  is  large  the  pulse  is 
small  and  irregular. 

Pericardial  effusion  takes  weeks  to  absorb,  and  when 
large  in  amount  often  causes  death.  The  prognosis  of  puru- 
lent effusion  is  bad  even  when  it  is  small  in  quantity  ;  the 
"rheumatic"  cases  are  the  most  favourable. 

Differential  diagnosis. — Pericarditis  externa  is  differen- 
tiated by  the  fact  that  the  friction  is  influenced  by  the  breath 
sounds.  It  is  often  difficult  to  distinguish  pericardial  bruits 
from  endocardial  when  the  right  ventricle  is  dilated.  The 
character  of  the  ''  rub,"  its  definite  localization  at  a  certain 
spot,  the  fact  that  it  does  not  absolutely  correspond  with 
the  cardiac  phases,  and  the  increased  distinctness  when 
the  stethoscope  is  pressed  on  the  thoracic  wall,  will  clear 
up  the  diagnosis.  In  doubtful  cases,  according  to  Romberg, 
the  most  reliable  signs  are  the  gradual  increase  in  the  area 
of  dullness  and  the  remarkable  correspondence  of  relative 
and  absolute  dullness. 

INDICATIONS   FOR   OPERATION. 

When  the  heart  begins  to  fail  from  the  pressure  of  a  large 
pericardial  effusion,  puncture  of  the  pericardial  sac  is 
absolutely  indicated.  Puncture  is  also  indicated  when  a 
large  effusion  persists  in  spite  of  prolonged  medical  treatment, 
and  is  gradually  enfeebling  the  patient.  When  pus  is 
present  in  the  pericardium,  the  latter  must  always  be  freely 
opened  unless  the  general  condition  is  desperately  bad.  An 
exploratory  puncture  will  demonstrate  the  character  of  the 
fluid.  An  effusion  is  probably  purulent  when  there  is  pus 
in  the  pleura  and  inflammatory  oedema  of  the  chest  wall. 

Contra-indications. — Operation  is  only  contra-indicated  by 
the  presence  of  advanced  disease  elsewhere,  such  as  pro- 
nounced valvular  lesions,  new  growths,  phthisis,  Bright's 
disease. 

Risks  of  operation. — The  risks  are  considerable,  because 
the  heart  muscle  is  usually  affected.  The  right  mammary 
artery  and  even  the  right  ventricle  have  been  wounded. 
Obliteration  of  the  pericardial  sac  often  follows  operation, 
and  is  a  serious  lesion. 


DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS.    143 

Prognosis. — In  many  desperate  cases  recovery  has  been 
brought  about  by  operation  ;  v.  Schrotter  records  47 
recoveries  and  53  deaths  in  100  cases, — but  it  should  be 
remarked  that  only  the  most  serious  cases  have  hitherto 
been  submitted  to  operative  treatment. 

LITERATURE. 

V.  Schrotter.  Erkrankungen  des  Herzbeutels.  Nothnagel's 
Handbuch.     Wien,   1894.     Bd.  xv.,  Teil  2. 

Romberg.  Krankheiten  des  Herzbeutels.  Spez.  Pathol,  u.  Therap. 
von  Ebstein-Schwalbe.     Stuttgart,    1899.     Bd.  i. 

V.  Elsberg.  Incision  des  Herzbeutels.  Wien.  klin.  Wochens. 
1895,  No.  2. 


ANEURYSM. 

Etiology. — Arteriosclerosis  is  the  most  important  cause 
of  aneurysm  ;  hence  its  relative  rarity  in  young  subjects. 
All  the  conditions  which  produce  atheroma  : — alcoholism, 
laborious  occupations,  etc.,  favour  the  development  of 
aneurysm.  Other  factors  are  syphilis  and  trauma — and 
the  latter  may  be  either  single  and  severe,  or  slight  and 
repeated.  Embolism  of  the  smaller  arteries  may  produce 
"  embolic  "  aneurysm,  and  "  erosion  "  aneurysms  occur 
from  erosion  of  vessels  from  the  outside. 

Pathological  Anatomy. — The  term  aneurysm  is  applied 
only  to  circumscribed  arterial  dilatation  ;  diffuse  dilatation 
such  as  that  met  with  in  aortic  incompetence  and  atheroma 
are  not  so  designated.  In  true  aneurysm  all  the  walls  of 
the  vessel  participate  in  the  formation  of  the  sac,  in  false 
aneurysm  the  sac  is  formed  by  some  part  of  the  vessel  wall 
along  with  surrounding  structures.  Aortic  dilatations 
may  be  fusiform  or  saccular.  In  fusiform  aneurysms 
coagulation  and  thrombus  formation  is  rare ;  in  the  saccular 
aneurysms  it  is  common,  but  organization  of  thrombus  is 
very  rare.  The  sac  may  communicate  with  the  artery  by  a 
large  or  a  small  aperture,  it  is  often  extremely  adherent  to 
its  surroundings,  and  erodes  any  bony  structures  with  which 
it  is  in  contact. 

Aneurysms  of  the  aorta  constitute  about  a  half  of  all 
aneurysms  in  man  ;  they  may  involve  secondarily  any 
structure  in  the  mediastinum,  either  by  simple  compression 
or  by  the  formation  of  adhesions  in  addition;  ribs,  clavicle, 


144  INDICATIONS    FOR    OPERATION    IN 

or  vertebrae  may  be  eroded.  In  large  aneurysms  in  place  of 
a  single  sac  there  may  be  secondary  or  tertiary  protrusions 
communicating  with  the  primary  sac  by  apertures  of 
greater  or  less  size.  When  an  aortic  aneurysm  penetrates 
the  thoracic  wall  this  almost  always  takes  place  through 
the  formation  of  a  secondary  protrusion  from  a  saccular 
aneurysm — a  fact  of  much  importance  from  the  point  of 
view  of  surgical  treatment.  In  the  neighbourhood  of  an 
aneurysm  there  is  almost  always  great  overgrowth  of  fibrous 
tissue  embracing  the  wall  ;  this  assists  in  preventing 
perforation  in  the  early  stages,  but  is  not  equal  to  preventing 
it  later. 

Rupture  may  take  place  externally  or  into  a  hollow 
organ  or  a  serous  cavity.  Rupture  into  an  adjacent 
vein  produces  the  so-called  varicose  aneurysm  ;  a  dissecting 
aneurysm  is  one  formed  in  the  vessel  wall  itself  by  rupture 
of  the  inner  coat.  The  vessels  originating  near  the  aneurysm 
undergo  changes  :  traction  may  make  their  orifices  slit-like, 
thrombosis  and  endarteritis  may  in  part  obstruct  them,  or 
they  may  be  directly  compressed.  Genuine  spontaneous 
healing  of  aneurysm  is  very  uncommon. 

Clinical  Course. — The  clinical  signs  and  symptoms  of 
aneurysm  are  various. 

Aneurysm  of  the  ascending  aorta  and  arch,  as  all  other 
vascular  tumours,  produce  subjective  and  objective 
phenomena.  Pain,  often  of  the  character  of  angina  pectoris, 
is  the  chief  subjective  sign,  and  objectively  there  are  found 
displacement  and  compression  of  neighbouring  organs  and 
the  development  of  a  pulsating  tumour. 

An  aneurysm  confined  to  the  thorax  is  often  discovered 
by  chance,  either  from  a  radiograph  or  on  percussing  the 
chest,  or  in  the  course  of  a  laryngoscopic  examination. 
Marked  accentuation  of  the  first  or  second  sounds  over  the 
course  of  the  aorta,  or  bruits  superadded  to  these  in  the  same 
region,  will  raise  the  suspicion  of  aneurysm.  Dullness  in 
the  first  and  second  intercostal  spaces  close  to  the  sternum, 
pronounced  pulsation  in  the  suprasternal  region,  pulsatile 
elevation  of  the  upper  part  of  the  sternum,  and  pulsation 
to  the  right  of  the  manubrium,  are  definite  signs  of  aneurysm. 
Associated  with  or  independent  of  these  signs  there  may  be 
distinct  difference  in  distension  of  the  carotids  or  subclavians, 
much  more  rarely,  a  delay  in  the  right  radial  as  compared 


DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS.     145 

with  the  left,  or  vice  versa.  Paralysis  of  the  left  recurrent 
laryngeal  nerve  and  corresponding  vocal  cord  is  frequent, 
also  localized  pulsatile  elevation  of  the  tracheal  wall,  left 
bronchial  stenosis,  a  laryngeal  tug,  and  more  or  less  marked 
oesophageal  obstruction.  When  the  vertebrae  are  eroded 
there  is  local  tenderness  on  pressure,  and  rigidity,  with 
unilateral  or  bilateral  intercostal  neuralgia. 

If  the  sternum  or  the  ribs  are  eroded,  the  aneurysm  may 
present  as  a  pulsatile  and  expansile  hemispherical  tumour. 
When  a  saccular  aneurysm  of  the  arch  causes  bronchial 
stenosis  there  is  stridor  and  interference  with  the  respiratory 
cycle  on  the  left  side  ;  an  aneurysm  situated  here  also  often 
causes  left  sympathetic  paralysis,  but  venous  compression 
is  rare  even  in  the  case  of  large  tumours. 

Aneurysms  of  the  descending  thoracic  aorta  are  compara- 
tively rare ;  they  may  present  all  the  above-named 
symptoms,  but  more  often  are  only  revealed  by  the  presence 
of  a  circumscribed  dullness.  Sometimes  aneurysms  are  very 
elongated  in  outline.  I  have  seen  a  case  in  which  an 
aneurysm  of  the  arch  extended  into  the  neck  from  the  origin 
of  the  carotid  to  the  upper  third  of  the  trachea  ;  death  took 
place  from  rupture  into  the  trachea. 

Aneurysm  of  the  abdominal  aorta  is  very  uncommon  ;  it 
is  revealed  by  palpation  and  auscultation. 

Diagnosis  and  Differential  Diagnosis. — Aneurysms 
suitable  for  operation  cannot  be  confounded  with  many 
other  affections.  Simple  atheroma  of  the  aorta  does  not 
erode  and  push  forward  the  sternum.  Very  vascular  new 
growths  sometimes  give  rise  to  considerable  difficulties. 
Venous  distension  over  the  thoracic  wall  points  to  new 
growth,  as  do  also  glandular  enlargements,  the  presence  of 
tumours  elsewhere,  marked  cachexia,  and  soft  systolic  and 
diastolic  bruits  over  the  swelling.  The  absence  of  expansile 
pulsation  is  against  aneurysm  ;  abscesses  as  well  as  new 
growths  may  have  pulsation  communicated  from  the  aorta, 
and  are  differentiated  from  aneurysm  by  the  same  sign. 
A  pointing  pulsatile  empyema  is  to  be  distinguished  by 
the  history,  the  position  of  the  heart,  and  by  exploratory 
puncture. 

INDICATIONS   FOR   OPERATION. 

Different  operative  measures  have  been  employed,  and 
indications  vary  according  to  their  severity.     Complete  or 

10 


146  INDICATIONS    FOR    OPERATION    IN 

practically  complete  recovery  occurs  in  rare  cases  by  organi- 
zation of  clot.  Such  an  event  occurs  almost  exclusively  iv 
saccular  aneurysms  communicating  with  the  vessel  by  a  small 
aperture  ;  in  fusiform  aneurysms  it  is  exceedingly  unusual. 
If  an  aneurysmal  sac  has  developed  secondary  extensions, 
as  is  almost  always  the  case  in  those  penetrating  towards 
the  surface  of  the  chest,  the  prognosis  is  unfavourable, 
but  even  in  these  some  improvement  may  be  brought 
about.  When  the  sufferings  of  the  patient  are  great, 
the  possibility  of  improving  or  relieving  him  of  some 
of  his  symptoms  by  surgical  intervention  is  well  worth 
consideration. 

Operation  is  therefore  in  a  measure  indicated  when  the 
physical  signs  point  to  the  presence  of  a  saccular  aortic 
aneurysm  with  a  narrow  neck  ;  a  skiagram  may  be  of  great 
assistance.  There  are,  however,  other  points  to  be  con- 
sidered :  the  aneurysm  should  not  be  deep  seated,  but  should 
underlie  the  thoracic  wall  or  extend  beyond  the  limits  of 
the  chest  above*  ;  the  condition  of  the  heart  must  be  good 
without  dilatation,  and  such  serious  complications  as 
extensive  atheroma  must  be  absent.  Medical  treatment 
should  always  be  first  tried,  and  operation  will  only  be  con- 
sidered when  this  has  failed.  The  operation  of  Brasdor, 
ligature  of  the  common  carotid,  or  subclavian,  or  both,  does 
not  require  that  an  aneurysm  should  be  saccular  and  possess 
a  narrow  neck,  but  may  be  employed  in  the  absence  of  these 
conditions.  Acupuncture,  galvanopuncture,  and  the  intro- 
duction of  foreign  material  into  the  sac  have  the  same 
general  indications  :  the  aneurysm  should  present  near  the 
surface,  the  general  state  of  health  must  be  satisfactory, 
other  vascular  changes  must  not  be  of  an  advanced  type, 
and  the  aneurysm  should  be  connected  with  the  main  vessel 
by  a  more  or  less  narrow  neck.  The  subjective  condition 
of  the  patient  should  have  considerable  weight  attached  to 
it;  if  his  sufferings  are  extreme,  operation  may  be  justifiable 
even  though  its  chances  of  success  seem  small.  Sub- 
cutaneous injections  of  gelatin  may  be  employed  whatever 
the  site  and  size  of  an  aneurysm,  but  according  to  Sorgo  it 


*  Many  writers  do  not  consider  this  condition  necessary,  and  would 
recommend  operation  whether  the  aneurysm  protrudes  from  the  thorax 
or  not. 


DISEASES  OF  THE  HEART  AND  BLOOD. VESSELS.     147 

is  only  in  the  saccular  form  that  there  is  a  prospect  of 
success. 

Contra-indications. — These  have  been  already  generally 
indicated.  When  the  sac  wall  is  very  thin  Brasdor's 
operation  is  contra-indicated  for  fear  of  rupture.  When 
there  are  valvular  lesions,  or  when  the  aneurysm  is  of  great 
size,  no  operation  will  be  done.  When  the  trachea  is  com- 
pressed, tracheotomy  is  not  advisable,  because  the  pressure 
of  the  tube  is  very  likely  to  lead  to  rupture  of  the  aneurysm 
into  the  trachea.  I  have  seen  this  happen  twice  a  few  days 
after  tracheotomy.  In  patients  with  renal  disease  gelatin 
injections  are  contra-indicated. 

Risks  of  operation  in  internal  aneurysm.  In  acupuncture, 
galvanopuncture,  and  the  introduction  of  foreign  matter 
into  the  sac,  experience  has  shown  that  the  danger  of  profuse 
haemorrhage  from  the  wound  is  not  great  ;  but  when  these 
measures  are  employed,  and  the  communication  with  the 
aorta  is  large,  emboli  may  be  carried  into  the  arterial 
system.  The  dangers  of  Brasdor's  operation  are  those 
associated  with  carotid  ligature  and  subclavian  ligature ; 
that  is  to  say,  cerebral  anaemia  and  softening  on  the  one 
hand  and  gangrene  of  the  arm  on  the  other.  Extensive 
thrombosis  of  peripheral  vessels  may  follow  gelatin  injec- 
tions, and  tetanus  is  a  risk  if  the  most  careful  precautions 
are  not  taken. 

Prognosis. — The  prospect  of  cure  is  small  whatever 
operative  measures  are  employed,  but  long-lasting  improve- 
ment may  be  produced.  In  a  case  reported  by  Stewart 
which  was  treated  by  galvanopuncture,  improvement  lasted 
three  years ;  in  a  case  of  Baumler's  it  lasted  two  years  after 
acupuncture  following  Brasdor's  operation.  Cure  has  been 
brought  about  in  a  relatively  large  number  of  cases  by 
Brasdor's  operation,  and  the  prognosis  is  particularly  good 
in  innominate  aneurysms.  In  many  cases,  however,  opera- 
tion has  no  influence  on  the  progress  of  the  condition. 

When  no  operation  is  undertaken,  recovery  occurs  very 
rarely  spontaneously  or  under  medical  treatment,  but  by 
the  latter  means  and  dietetic  regulation  progress  may  be 
checked  and  the  condition  improved.  Death  occurs  in 
the  large  majority  of  cases  from  rupture  of  the  sac  or 
other  complicatior. 


148  INDICATIONS    FOR    OPERATION    IN 

LITERATURE. 

V.  ScROTTER.  Die  Erkrankungen  der  Gefasse.  Nothnagel's 
Handbuch  d.  spez.  Pathol,  u.  Therap.   Wien,  1899.    Bd.  xv.,  Teil  iii. 

Ch.  Baumler.  Die  Behandlung  d.  Aneurysmen.  Handbuch  d. 
Therap.    von  Penzoldt-Stintzing.     Bd.  iii.     2nd  Ed. 

Romberg.  Die  Krankheiten  der  Gefasse.  Handbuch  der  prakt. 
Med.     von  Ebstein-Schwalbe.     Stuttgart,  1898.     Bd.  i. 

Quincke.     Aneurysmen.     Ziemssen's  Handbuch.     Bd.  v. 

Stewart.  On  the  Treatment  of  Aneurysm.  Brit.  Med.  Jour., 
Aug.  14th,  1897. 

Mace  WEN.     Aneurysm.     Lancet,    1890.     Vol.  ii.,    1086. 

Sorgo.  Die  Behandlung  d.  Aneurysmen  mit  Gelatine.  Therap. 
d.  Gegenwart,  1900. 

HYDROPS    ANASARCA. 

Indications  for  Operative  Treatment. — The  anasarca 
due  to  cardiac  and  renal  disease  is  alone  in  question ;  for  the 
oedema  of  cachexia  no  operation  is  justified.  There  is  some 
difference  of  opinion  as  to  the  best  time  for  operative  treat- 
ment ;  some  employ  it  only  when  all  other  therapeutic 
procedures  have  failed,  others  advise  it  early.  It  is  well  to 
follow  the  indications  formulated  by  Romberg  :  when 
diuretic  stimulation  fails  and  diaphoresis  is  impracticable  or 
ineffective,  and  the  condition  of  the  patient  calls  for  urgent 
relief  from  the  oedema,  puncture  of  the  skin  should  be 
employed.  This  is  a  vital  indication,  and  apart  from  this 
the  operation  is  advisable  when  the  anasarca  is  great  and 
distressing  to  the  patient,  and  is  unrelieved  by  drugs, 
particularly  if  the  general  condition  is  good.  Incision  may 
take  the  place  of  puncture  if  the  state  of  the  skin  is  not 
favourable  for  the  latter. 

Contra-indications. — Erysipelas,  phlebitis,  and  other 
extensive  inflammatory  processes  of  the  lower  limbs  contra- 
indicate  operative  treatment,  and  it  is  the  same  in  my 
experience  when  the  legs  are  in  a  condition  of  elephantiasis, 
with  much  thickening  of  the  skin  and  overgrowth  of 
connective  tissue  beneath — in  such  condition  only  very 
small  quantities  of  fluid  can  be  drawn  off.  If  the  patient  is 
stupid,  unreasonable,  and  unruly,  the  risks  are  considerable. 

Prognosis. — Risks  of  operation. — If  the  patient  is  difficult 
to  manage,  and  if  drainage  is  kept  up  for  a  long  time,  there 
are  risks  of  infection.  If  large  incisions  are  made  and  the 
fluid  escapes  very  rapidly,  the  drainage  may  be,  and  often 


DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS.     149 

has  been,  followed  by  collapse  and  sudden  death.  I  have 
seen  sudden  death  occur  several  times  on  the  second,  third, 
or  fourth  day  after  the  rapid  drawing  off  of  the  fluid,  and 
after  a  period  of  comparative  well-being,  and  I  consider  that 
at  the  most  four  litres  pro  die  should  be  removed  by  punc- 
ture or  scarification.  It  is  also  necessary  to  bear  in 
mind  that  scarification  and  puncture,  often  repeated,  result 
in  so  considerable  a  loss  of  albumin  that  amyloid  changes 
in  the  viscera  may  be  induced  thereby. 

Results. — Operative  treatment  often  saves  life  ;  the 
heart  is  considerably  relieved,  and  the  circulatory  disturbance 
may  then  right  itself.  The  subjective  condition  of  the  patient 
often  improves  greatly  in  the  course  of  a  few  hours ;  the  pains 
in  the  bones  and  the  dyspnoea  disappear.  Usually  puncture 
promotes  diuresis,  and  diuretics  and  cardiac  stimulants  are 
more  effective  after  than  before  it.  In  a  case  of  mine  of 
mitral  insufficiency  and  stenosis,  with  extreme  and  universal 
anasarca,  after  puncture  of  the  ascites  and  drainage  of  the 
skin  of  the  legs  for  some  days,  the  oedema  entirely  disappeared, 
and  remained  absent  absolutely  for  three  years. 

LITERATURE. 

GuMPRECHT.  Die  Chir.  Behandlung  der  Hautwassersucht  einst 
und  jetzt.  Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.  1899. 
Nos.  1-3. 

FuRBRiNGER.  Bchandlung  des  Hydrops.  Deut.  med.  Wochens. 
1899.     No.  I. 

RoTMANN.  Die  Chir.  Behandlung  der  Hautwassersucht.  Deut. 
med.  Wochens.      i8q6.     No.  48. 

Romberg.  Behandlung  d.  Herzkrank.  Handbuch  der  prakt. 
Med.  von  Ebstein-Schwalbe.     Bd.  i.,  p.  912. 

Krcnig.  Operative  Behandlung  der  Hautwassersucht.  Ver- 
handlung  des  Kongresses  f.  innere  Med.,  1897,  p.  555. 


CHAPTER     X. 

The   Indications   for   Venesection. 


153 


Chapter   X. 
THE     INDICATIONS     FOR     VENESECTION. 

Venesection,  once  so  common  and  then  abandoned,  is 
again  employed  to-day  under  certain  circumstances.  The 
two  fundamental  indications  -  are  the  removal  of  toxic 
products  and  the  relief  of  the  circulation  ;  it  is  no  longer 
done  on  ' '  antiphlogistic  "  principles.  The  most  generally 
accepted  indications  are  as  follows : — 

INTOXICATIONS. 

In  the  intoxications  venesection  is  an  important  thera- 
peutic agent,  in  particular  in  the  cases  of  poisons  which 
concentrate  themselves  in  the  blood  and  directly  affect  it. 
As  much  as  300-400  cc.  may  be  drawn  off  from  patients 
suffering  from  the  effects  of  the  inhalation  of  poisonous  gases : 
sulphuretted  hydrogen,  coal  gas,  carbonic  oxide,  hydro- 
cyanic acid,  and  anaesthetic  nitrous  oxide.  The  risks  of  the 
blood-letting  are  minimal  compared  with  those  to  which  such 
patients  are  exposed,  particularly  if  followed  immediately 
by  transfusion  of  saline  ;  the  risks  are  greatest  in  anaemic 
and  least  in  full-blooded  individuals. 

INSOLATION. 

In  insolation  bleeding  is  indicated  when  internal  rnedica- 
tion  fails  and  convulsions  make  their  appearance.  Of 
twenty  cases  thus  treated  Gerand  lost  none. 

UREMIA. 

In  uraemia  bleeding  should  always  be  tried  ;  when 
attacks  come  on  suddenly  and  other  methods  fail,  life  has 
often  been  saved  by  this  means.  The  risk  is  comparatively 
insignificant.     In  the  clironic  forms  of  uraemia,  in  which  the 


154  THE     INDICATIONS     FOR 

patient  may  remain  for  weeks  in  a  somnolent  condition, 
interrupted  by  attacks  of  dyspnoea  and  vomiting,  bleeding 
may  be  of  great  use  on  the  onset  of  convulsions  or  coma. 
According  to  Strubell  the  abstraction  of  blood  and  trans- 
fusion of  saline  has  sometimes  saved  life  under  these 
circumstances.  This  form  of  chronic  uraemia  is  usually 
associated  with  idiopathic  or  secondary  interstitial  nephritis. 
Bleeding  is  also  of  great  value  in  uraemia  due  to  acute  and 
subacute  nephritis  ;  according  to  Leube  it  lessens  the  gravity, 
the  risks,  and  the  length  of  the  attacks. 

ECLAMPSIA. 

According  to  Zweifel  copious  bleeding  up  to  500  cc. 
is  advisable  in  this  affection.  It  is  valuable  as  a 
preliminary  to  the  production  of  artificial  labour,  and  the 
combination  of  these  two  procedures  has  given  results 
superior  to  all  other  methods  of  treatment,  deep  cervical 
incisions  and  the  like.  It  is  absolutely  indicated  when 
eclampsia  comes  on  during  labour,  or  persists  after  natural 
or  artificial  delivery. 

PNEUMONIA. 

Bleeding  is  only  indicated  in  pneumonia  in  the  presence 
of  established  or  commencing  pulmonary  oedema  associated 
with  commencing  heart  failure.  Feebleness  of  the  second 
pulmonary  sound  indicates  the  onset  of  heart  failure  ; 
bleeding  often  gives  such  relief  that  the  patient's 
strength  is  thereby  enabled  to  hold  out  until  the  crisis. 
Under  these  circumstances  the  indication  is  absolute  unless 
some  other  dangerous  lesion  is  present  elsewhere  or  the 
enfeeblement  of  the  patient  is  already  extreme.  I  have 
often  seen  venesection  save  life  in  pneumonia,  especially 
in  patients  with  some  heart  lesion. 

CIRCULATORY    DISTURBANCE. 

In  circulatory  disturbance  due  to  valvular  or  myocardial 
lesions  the  indications  for  venesection  are  not  definitely 
determined.  According  to  H.  Pavy  it  is  indicated  in 
commencing  heart  failure,  dilatation  of  the  right  ventricle 
with  progressive  dyspnoea,  commencing  oedema  of  the  bases, 


VENESECTION.  155 

and  diminished  pulmonary  second  sound.  It  is  indicated 
early,  according  to  Strubell,  in  bronchitis  of  a  severe  type, 
and  pneumonia  in  alcoholic  subjects.  In  chronic  heart 
disease  its  effect  is  transient,  and  in  several  patients  thus 
affected  bleeding  has  been  followed  by  thrombosis,  for 
example  in  the  basilar  artery. 

CHLOROSIS. 

Venesection  has  been  employed  in  chlorosis,  but  is  not 
to  be  recommended. 

LITERATURE. 

Strubell.  Der  Aderlass.  Zentralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Cliir.,    1902. 

Jaksch.  Ueber  die  Therap.  Wert  der  Blutentziehungen.  Prager 
med.  Wochens.      1894,  32-35. 

NcNNE.  Aderlass  bei  Chlorose.  Aertzl.  Verein  zu  Hamburg,  25 
Juni,  1895.     Deut.  med.  Wochens.      1896. 

Leube.  Nierenkrankheiten.  Handbuch  d.  Therap  von  Penzoldt- 
Stintzing.     Bd.  vi. 

ZwEiFEL.  Zur  Behandlung  der  Eklampsie.  Zentralb.  f.  Gynak., 
1895,     No.  46. 

AuFRECHT.  Lungenentziindungen.  Nothnagel's  Handbuch  d.  spez. 
Pathol.     Bd.  xiv. 

B.4.UMLER.  Kreislaufsstorungen.  Handbuch  d.  spez.  Therap. 
von  Penzoldt-Stintzing,  Bd.  hi.     2nd  Ed. 

Pavy.  The  Indications  for  Bleeding.  Birmingham  Med.  Review. 
Dec,  1900. 


CHAPTER    XL 
Diseases    of  the    Mouth    and    Pharynx. 


159 


Chapter  XI. 
DISEASES  OF  THE  MOUTH  AND  PHARYNX. 

HYPERTROPHY    OF    THE    TONSILS. 

Etiology. — There  often  appears  to  be  some  hereditary- 
tendency  to  this  condition.  It  may  follow  repeated  attacks 
of  tonsillitis,  and  is  also  associated  with  the  so-called 
scrofulous  condition. 

Pathological  Anatomy. — Tonsillar  hypertrophy  is 
usually  bilateral,  and  often  so  considerable  as  to  markedly 
obstruct  the  pharyngeal  channel.  The  tonsils  are  sometimes 
soft,  sometimes  hard,  and  often  fissured.  The  crypts  often 
contain  calculi,  plugs  of  mucus,  or  pus,  the  latter  often  only 
revealed  on  squeezing  the  tonsil,  and  associated  with 
thrombosis  of  the  neighbouring  veins.  I  have  seen  several 
cases  of  fatal  septiceemia  due  to  such  purulent  collections 
only  revealed  by  a  specially  careful  examination  at  autopsy. 

Clinical  Signs. — Tonsillar  hypertrophy  favours  recurrent 
attacks  of  inflammatory  mischief,  attacks  which  it  is  now 
well  recognized  are  far  from  being  harmless.  When  hyper- 
trophy is  marked,  respiration  is  prejudiced,  especially 
during  sleep,  and  there  are  difficulties  of  phonation  and 
deglutition.  Pharyngeal  catarrh  often  co-exists,  and  the 
Eustachian  tubes  and  middle  ear  are  then  frequently 
affected.  The  pharyngeal  adenoid  tissue  is  also  very  often 
hypertrophied. 

INDICATIONS   FOR   TONSILLOTOMY. 

Hypertrophied  tonsils  should  be  removed  if  they  are 
giving  rise  to  the  least  trouble.  The  operation  is  therefore 
indicated  when  the  tonsils  are  subject  to  repeated  attacks 
of  inflammation,  when  there  are  disturbances  of  phonation 
or  deglutition,  when  there  are  any  signs  of  middle-ear 
trouble  or  deafness,  or  when  sleep  is  disturbed  and  restless. 


i6o  ■   INDICATIONS    FOR    OPERATION    IN 

Contra-indications. — Haemophilia  and  leukcemia  are  the 
only  contra-indications. 

Prognosis. — Risks  of  operation. — These  are  minimal. 
Occasionally  troublesome  haemorrhage  has  occurred  from  the 
tonsillar  branch  of  the  pterygopalatine  (O.  Zuckerkandl). 
In  one  case  of  unrecognized  lijemophilia  under  my  care  the 
operation  caused  dangerous  haemorrhage. 

If  no  operation  is  done  the  tendency  to  tonsillitis  will 
remain,  with  the  risks  of  middle-ear  disease,  pharyngitis, 
extensive  suppuration,  and  septicaemia. 

LITERATURE. 

Frankel.  Article  "  Tonsillen  "  in  Eulenberg's  Realency- 
klopadie. 

LiCHTWiTZ.     Archiv.  fiir  Laryngologie.     Bd.  ii. 

Stork.  Erkrankungen  der  Nase  und  des  Rachens.  Nothnagel's 
Handbuch  d.  spez.  Pathol. 

Fleiner.  Krankheiten  der  Verdauungsorgane.  Teil  i.  Stutt- 
gart, 1896. 

SEPTIC    PHARYNGITIS. 

Etiology. — This  affection  is  frequently  due  to  the  strepto- 
coccus, and  may  be  secondary  to  infections  elsewhere  in  the 
mouth,  for  example  in  the  tonsils  and  the  teeth.  It  is 
common  in  diphtheria  and  scarlatina. 

Pathological  Anatomy. — The  inflammatory  process 
affects  the  connective  tissue  between  the  tonsils  and  the  soft 
palate,  or  the  substance  of  the  tonsils  themselves.  As  a 
rule  the  process  goes  on  to  suppuration  ;  sometimes  it 
extends  widely  in  the  connective  tissue  of  the  neighbourhood, 
and  may  occasion  an  intense  phlegmonous  inflammation  of 
the  floor  of  the  mouth  and  the  pharynx,  with  marked 
collateral  oedema  ;  this  sometimes  involves  the  entrance  to 
the  larynx,  and  in  fatal  cases  this  is'  the  cause  of  death. 

Clinical  Course. — There  is  usually  high  fever,  and  much 
pain  is  complained  of,  particularly  on  swallowing  and 
opening  the  mouth.  Examination  shows  marked  swelling 
and  dusky  red  coloration  of  the  soft  palate  (usually  more 
intense  on  one  side),  of  the  anterior  pillars,  and  often  of  the 
tonsils  themselves  ;  the  surrounding  parts  are  oedematous, 
particularly  the  uvula  and  faucial  pillars,  more  rarely  the 
laryngeal  entrance.  After  some  days  suppuration  occurs  ; 
this  is  first  deeply  situated,  and  later  comes  to  the  surface. 


DISEASES    OF    THE    MOUTH   AND    PHARYNX.     i6x 

Usually  after  about  a  week  the  pus  escapes  ;  in  a  relatively- 
small  number  of  cases,  however,  the  process  goes  on  to  an 
extensive  phlegmonous  inflammation  of  the  floor  of  the 
mouth,  the  so-called  Angina  Ludovici,  and  this  may  produce 
a  fatal  acute  oedema  of  the  glottis. 

INDICATIONS   FOR  OPERATION. 

As  soon  as  pus  is  suspected  incisions  should  be  made, 
whether  the  collection  appears  to  be  superficial  or  deep. 
Incision  is  therefore  called  for  when  the  signs  and  symptoms 
above  described  have  been  present  for  several  days  ;  if 
the  pain  is  very  intense,  early  deep  incision  is  advisable  ; 
in  other  cases  it  is  well  to  wait  until  an  abscess  has 
definitely  developed  (Stork  recommends  that  one  should 
always  wait  until  fluctuation  is  discovered)  ;  certainly, 
at  whatever  stage  fluctuation  is  found  an  incision  will  at 
once  be  made. 

It  may  be  said  that  no  contra-indications  exist. 

Prognosis.— Resulis  of  incision. — The  patient  is  at  once 
relieved,  and  the  inflammation  subsides.  If  pus  is  not 
found  at  the  time  of  incision,  it  may  be  expected  that  it 
will  come  to  the  surface  and  escape  through  the  incision  in 
the  course  of  a  few  hours  or  days.  There  is  no  risk  when 
the  incision  is  made  at  the  right  spot,  that  is  to  say  in  the 
centre  of  the  space  between  the  uvula  and  the  crown  of  the 
upper  wisdom  tooth. 

//  no  incision  is  made,  the  symptoms  may  persist  for  a 
considerable  time,  and  sometimes  as  a  consequence  there 
occur  oedema  of  the  glottis,  Ludwig's  angina,  or  extensive 
abscess  burrowing.  Such  an  abscess  may  even  extend  into 
the  mediastinum. 

LITERATURE. 

Stork.  Krankheiten  der  Nase,  des  Rachens.  Nothnagel's  Hand- 
buch  d.  spez.  Pathol.     Wien,  1895. 

Strubixg.  Krankheiten  des  Rachens.  Handbuch  d.  prakt.  Med. 
von  Ebstein-Schwalbe.     Bd.  i.      1899. 

RETROPHARYNGEAL  ABSCESS 
AND  RETROPHARYNGEAL  CELLULITIS. 

Etiology. — In  young  children  the  most  frequent  cause 
of    retropharyngeal    abscess    is    suppuration    of     the    two 


i62  INDICATIONS    FOR    OPERATION    IN 

prevertebral  lymphatic  glands,  which  are  constantly  present 
in  front  of  the  second  and  third  cervical  vertebrae  ;  it  is 
secondar}'  in  these  cases  to  inflammatory  affections  of  the 
pharynx.  The  other  common  cause  is  a  tuberculosis  of 
the  vertebral  bodies.  I  have  seen  two  cases  in  which  the 
primary  affection  was  a  syphilitic  lesion  of  the  cervical 
spine,  but  this  is  very  rare.  Sometimes  these  inflammatory 
processes  are  due  to  some  general  infection,  or  may  follow 
trauma,  in  particular  cauterization,  of  the  posterior  wall 
of  the  pharynx.  Occasionally  a  retropharyngeal  abscess 
is  secondary  to  a  chronic  otitis  media. 

Clinical  Signs. — Retropharyngeal  abscess  produces  a 
series  of  characteristic  symptoms.  The  posterior  pharyngeal 
wall  is  swollen,  and  fluctuation  can  be  made  out;  swallowing 
and  expectoration  are  painful  and  difficult  ;  when  the 
condition  is  well  established  no  solid  food  can  be  swallowed, 
and  fluids  also  cause  difficulty,  and  tend  to  return  through 
the  nose  or  the  mouth.  Speech  is  guttural,  as  though  the 
patient  had  his  mouth  full  of  food,  and  breathing  is  difficult 
and  snoring,  particularly  with  the  head  inclined  forwards. 
Asphyxial  attacks  sometimes  come  on  when  the  patient  is 
lying  down.  In  acute  abscesses  there  is  often  high  fever  ; 
in  the  chronic  form  it  may  be  absent.  Acute  cellulitis 
may  cause  pronounced  prostration  and  symptoms  of  septic 
intoxication.  There  are  often  enlarged  and  tender  glands 
below  the  jaw,  and  oedema  about  the  laryngeal  inlet. 

Differential  Diagnosis. — The  presence  of  fluctuation 
differentiates  abscess  from  tumour,  simple  lymphadenitis, 
and  adenoids. 

INDICATIONS   FOR   OPERATION. 

As  soon  as  abscess  is  definitely  diagnosed  it  should  be 
incised.  It  should  be  opened  in  the  neck  when  it  is  of 
very  large  size,  when  it  is  due  to  tubercular  vertebral 
disease  or  to  the  presence  of  a  foreign  body,  and  when  there 
is  severe  pharyngeal  cellulitis.  The  common  retropharyngeal 
abscess  should  be  opened  from  the  mouth  when  the  diagnosis 
is  clear.  If  no  fluctuating  spot  can  be  found,  if  the  respira- 
tion is  very  embarrassed,  or  if  there  is  commencing  oedema 
glottidis,  tracheotomy  is  indicated.  When  suppuration  is 
definitely  made  out  there  are  no  contra-indications  to 
operation. 


DISEASES    OF    THE    MOUTH    AND    PHARYNX.     163 

Prognosis. — Risks  of  operation. — If  a  large  quantity  of 
pus  enter  the  larynx,  asphyxia  may  occur  or  pneumonia 
may  follow. 

//  no  operation  is  done,  death  may  occur  from  asphyxia, 
the  abscess  may  make  its  way  into  the  mediastinum,  or 
septicaemia  may  supervene.  In  Bokai's  statistics  11  out  of 
144  cases  of  retropharyngeal  abscess  died. 

LITERATURE. 

Fleiner.  Erkrankungen  der  Verdauungsorgane,  Teil  i.  Stutt- 
gart :    E.  Enke. 

ScHECH.     Krankheiten  der  Mundhohle  und  des  Rachens.    4th  Ed. 

Alexy.  Retropharyngealabscesse.  Jahrb.  f.  Kinderheilk., 
1892,  Neue  Folge,  Bd.  xvii. 

Neumann.  Akute  Entziindung  der  Retropharyngeal  Lymph- 
driisen.     Arch.  f.  Kinderheilk,  Bd.  xv. 


CHAPTER    XII. 

Diseases    of   the    CEsophagus. 


16; 


Chapter  XII. 
DISEASES    OF    THE    (ESOPHAGUS. 

FUSIFORM    DILATATION    OF    THE    (ESOPHAGUS. 

Etiology. — In  one  class  of  case  spasm  of  the  cardiac 
orifice  is  the  primary  cause ;  in  a  second  class  atony  and 
dilatation  of  the  oesophagus  is  the  primary  lesion,  followed 
by  spasm  of  the  cardia.  In  both  classes  the  time  of  onset 
is  usually  between  the  20th  and  40th  years.  It  is  usually 
an  acquired  condition,  and  equally  common  in  men  and 
women. 

Pathological  Anatomy. — The  dilatation  begins  usually 
just  below  the  level  of  the  larynx,  increases  throughout  the 
middle  and  lower  thirds,  sometimes  to  enormous  dimensions 
(in  Rokitansky's  case  to  the  size  of  a  man's  forearm),  and 
then  reaches  normal  dimensions  again  at  about  the  lower 
1-2  cm.  The  size  of  the  dilatation  may  be  such  that  the 
oesophagus  will  hold  as  much  as  150G  cc.  The  cardiac 
orifice  is  usually  free  from  cicatricial  stenosis,  but  there  is 
often  local  hypertrophy  of  the  wall  here. 

Symptoms. — The  symptoms  are  chiefly  those  of 
oesophageal  stenosis.  If  food  and  fluids  cannot  be  got  into 
the  stomach  they  are  regurgitated  without  any  actual 
vomiting.  Rumination  is  common.  Examination  with  the 
stomach  tube  gives  most  important  information  ;  when  the 
tube  is  in  the  oesophagus  it  brings  up  quantities  of  altered 
food  material  free  from  hydrochloric  acid  or  pepsin  ;  when 
pushed  further  on  into  the  stomach,  which  often  necessitates 
the  overcoming  of  some  resistance,  food  material  is  siphoned 
up  containing  both  these  substances,  provided  the  condition 
of  the  stomach  is  healthy.  Such  an  observation  demon- 
strates the  presence  of  a  cavity  above  the  cardia.  The  same 
may  be  demonstrated  by  passing  one  tube  into  the  stomach 
and  a  second   into  the  oesophagus,  and  introducing  some 


i68  INDICATIONS    FOR    OPERATION    IN 

colouring  matter  through  the  latter  ;  the  coloured  fluid 
comes  through  the  oesophageal  but  not  through  the  stomach 
tube. 

Diagnosis  and  Differential  Diagnosis. — The  symp- 
toms just  mentioned  may  also  be  caused  by  an  oesophageal 
diverticulum  situated  at  a  low  level.  Leube's  sound  will 
often  settle  the  question.  If  this  passes  into  the  stomach 
without  difficulty  the  case  is  probably  one  of  concentric 
dilatation.  The  second  deglutition  sound  which  is  heard 
over  the  cardiac  orifice  is  altered  in  cases  of  fusiform 
dilatation ;  that  is  to  say,  it  may  be  postponed  several 
minutes  after  the  act  of  swallowing.  Sometimes  a  radio- 
graph gives  useful  information. 

INDICATIONS   FOR   OPERATION. 

Hitherto  gastrostomy  is  the  only  operative  procedure 
which  has  been  done  in  these  cases,  and  then  only  as  a 
last  resource  when  the  patient  threatens  to  die  of  starvation, 
that  is  to  say,  is  in  an  advanced  stage  of  the  condition. 
Rumpel  has  proposed  direct  operative  treatment,  but  the 
suggestion  has  not  been  followed. 

Prognosis. — Gradual  increase  is  the  rule  in  this  condition, 
and  death  may  follow  from  starvation.  In  many  cases  life 
tnay  be  prolonged  without  operation  for  ten  years  or  more, 
so  that  vitally  the  prognosis  is  not  entirely  unfavourable. 

LITERATURE. 

Neumann.  Die  einfache  gleichmassige  Erweiterung  der 
Speiserohre.     Zentralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.   1900. 

Krauss.  Krankheiten  der  Speiserohre.  Nothnagel's  Handbuch 
d.  spez.  Pathol.  1901. 

DIVERTICULUM    OF    THE    (ESOPHAGUS. 

Etiology. — There  are  two  types  of  this  condition  :  the 
pressure  diverticulum  and  the  traction  diverticulum.  The 
former  is  probably  due  primarily  to  some  congenital 
anomaly  of  the  nature  of  a  defect  in  the  lower  part  of  the 
pharyngeal  wall,  which  yields  when  some  traumatic  influence 
IS  brought  to  bear  on  it.  The  traction  diverticula  are 
produced  by  adhesions  following  some  inflammatory  affection 
in  the  parts  surrounding  the  oesophagus,  as,  for  example, 
lymphadenitis,  pleurisy,  pericarditis,  vertebral  disease,  etc. 


DISEASES    OF    THE    (ESOPHAGUS.  169 

Pathological  Anatomy. — The  traction  diverticula  are 
often  situated  at  the  level  of  the  tracheal  bifurcation  ;  they 
are  small,  and  clinically  of  little  importance.  Pressure 
diverticula  may  be  situated  high  up  or  in  the  lower  part. 
The  pharyngo-oesophageal  form  has  its  origin  in  some  weak 
spot  in  the  muscular  coat  of  the  pharynx,  usually  about  the 
level  of  the  cricoid  cartilage,  and  sometimes  communicates 
with  the  pharynx  by  quite  a  small  opening.  It  is  sacciform 
in  shape,  and  when  full  may  greatly  compress  the  oesophagus, 
by  the  side  of  which  it  lies.  It  may  reach  the  size  of  a  man's 
fist  ;  in  one  of  my  cases  the  capacity  was  a  quarter  of  a  litre. 
The  deep  diverticula  may  be  equally  large  and  originate  in 
the  anterior  wall  near  the  tracheal  bifurcation.  These 
diverticula  may  produce  an  inflammatory  reaction  around 
them,  and  become  firmly  adherent  to  other  structures;  the 
trachea  as  well  as  the  oesophagus  may  be  compressed.  The 
pressure  diverticula  have  a  lining  of  mucous  membrane. 

Symptoms. — The  traction  diverticula  do  not  produce  any 
symptoms  by  which  they  can  be  recognized  during  life. 
The  pressure  or  "Zenker's"  diverticula  give  rise  at  the 
beginning  to  slight  difficulty  in  swallowing,  irritation  in  the 
throat,  and  expectoration.  Vomiting  after  a  meal  is  common. 
In  the  later  stages,  when  the  condition  has  been  present 
for  some  years,  the  difficulties  in  swallowing  increase,  the 
sac  lills  at  the  beginning  of  a  meal,  and  the  food  material 
remains  there  and  decomposes.  By  traction  and  direct 
pressure  the  oesophagus  becomes  much  narrowed.  After 
a  varying  period  the  contents  are  vomited  ;  they  contain 
no  free  hydrochloric  acid,  but  sometimes  inverted  starch ; 
they  are  undigested  and  mixed  with  a  large  amount  of 
mucus.  In  about  a  third  of  the  cases  a  soft,  fluctuating 
swelling  is  to  be  found  in  one  or  both  supraclavicular 
regions,  and  over  this  bruits  can  be  made  out.  There  is 
often  excessive  foetor  of  the  breath.  A  sign  of  much 
importance  is  the  gradual  displacement  downwards  of  the 
site  of  compression,  taking  place  slowly  during  the  course  of 
some  years.  Examination  with  the  sound  and  skiagraphy 
may  both  be  of  much  assistance  in  forming  a  diagnosis. 
The  affection  is  one  of  old  age  and  eminently  chronic  ;  it 
may  cause  extreme  emaciation. 

In  a  case  recently  under  my  own  observation  a  difficulty 
in  swallowing  gradually  developed.     The  sound  was  arrested 


I70  INDICATIONS    FOR    OPERATION    IN 

at  a  point  28  cm.  from  the  teeth  ;  there  was  frequent 
vomiting  of  decomposed  food  material,  and  lavage  showed 
that  the  sac  was  capable  of  containing  about  a  quarter  of  a 
litre.  Lotheissen  was  able  to  see  the  entrance  to  the  sac 
and  guide  the  oesophageal  sound  past  it.  With  the  X-rays 
the  sac  was  well  seen  when  filled  with  bismuth,  and  a  U-shaped 
lead  sound  introduced  into  it  was  also  demonstrated.  It 
had  reached  the  thoracic  cavity  and  moved  with  respiration  ; 
the  mucous  membrane  was  ulcerated  in  patches,  and  there 
was  an  enormous  production  of  mucus.  Vomiting  was 
painless  and  occurred  on  coughing.  The  patient  could  only 
be  fed  by  enemata,  and  a  gastrostomy  was  done  at  a  time 
when  there  were  signs  of  commencing  pneumonia.  Death 
took  place  some  days  later,  and  the  large  diverticulum  was 
demonstrated  post  mortem  behind  the  oesophagus,  with 
commencing  carcinoma  at  its  entrance. 

The  deep-seated  diverticula  often  give  rise  to  stenosis 
phenomena  and  pain  only  when  the  sac  is  filled  during  the 
meal  ;  but  the  symptoms  may  be  in  general  very  similar 
to  those  of  the  diverticula  above,  and  the  physical  signs  are 
the  same.  For  radiographic  demonstration  the  patient  is 
fed  with  bismuth  and  mashed  potato. 

The  diagnosis  will  be  based  on  the  history,  the  presence 
of  the  tumour  in  the  neck,  the  examination  with  the  sound, 
and  the  age  of  the  patient.  The  chronic  course  of  the 
affection  will  distinguish  it  from  carcinoma,  and  the  history 
from  cicatricial  stenosis. 

INDICATIONS   FOR  OPERATION. 

If  there  is  impermeable  stenosis,  gastrostomy  may  be 
indicated,  and  from  the  point  of  view  of  the  life  of  the 
patient  it  may  be  said  to  be  as  successful  as  radical  extir- 
pation. It  is  particularly  indicated  in  debilitated  individuals 
who  first  come  under  observation  at  a  late  stage,  also  in 
patients  who  are  not  favourable  subjects  for  a  general 
anaesthetic,  and  thirdly,  when  stenosis  is  so  marked  that 
radical  operation  promises  little  success.  It  may  also  be 
undertaken  with  a  view  to  retrograde  dilatation  with 
sounds. 

Extirpation  of  the  diverticulum  may  be  undertaken  when 
it  is  situated  high  up,  whatever  its  size,  and  when  it  is 
interfering  with  feeding  and  causing  stenosis.     It  should 


DISEASES    OF    THE    (ESOPHAGUS.  171 

be  done  at  as  early  a  stage  as  possible.  It  is  not  free  from 
risk,  and  will  therefore  not  be  advisable  in  advanced  debility. 
Gastrostomy  is  practically  free  from  risk  ;  total  extirpation 
is  comparatively  dangerous. 

//  no  operation  is  undertaken,  the  condition  is  chronically 
progressive,  and  will  cause  a  very  distressing  death  from 
inanition. 

LITERATURE. 

Krauss.  Die  Erkrankungen  der  Speiserohre.  Nothnagel's 
Handbuch  d.  spez.  Pathol.     Bd.  xvi. 

H.  Starck.     Die  Divertikel  der  Speiserohre.     Leipzig,    1900. 

W.  Rosenthal.  Die  Pulsionsdivertikel  des  Schlundes.  Leipzig, 
1902. 

(ESOPHAGEAL    STENOSIS:    CICATRICIAL   AND 
CARCINOMATOUS. 

Etiology. — Cicatricial  stenosis  is  usually  due  to  scald  or 
the  burn  of  some  corrosive,  more  rarely  to  wound  or  other 
trauma.  Occasionally  it  is  due  to  the  pressure  and  adhesion 
of  lymphatic  glands  or  to  the  contraction  of  an  ulcer  caused 
by  a  perforating  diverticulum. 

Pathological  Anatomy. — The  stenoses  caused  by 
corrosion  tend  to  occur  at  the  natural  isthmuses  of  the 
oesophagus,  that  is  to  say,  at  the  level  of  the  cricoid  cartilage, 
and  at  the  cardia  or  immediately  above  it.  Such  strictures 
are  usually  annular;  if  their  extent  is  more  than  from  5  to 
10  cm.  they  are  spoken  of  as  cylindrical ;  sometimes  the  tube 
dilates  above,  and  this  dilatation  may  show  ulceration,  and 
may  even  go  on  to  perforation. 

Carcinoma  is  almost  always  primary  ;  very  rarely  a 
growth  of  the  cardiac  end  of  the  stomach  spreads  to  the 
oesophagus  ;  the  common  site  is  the  level  of  the  tracheal 
bifurcation.  Sometimes  the  growth  is  scirrhous  and 
produces  pronounced  stenosis,  sometimes  it  is  exuberant 
and  cauliflower-like.  Perforation  into  the  lung,  pericardium, 
and  other  organs  is  common,  and  the  mediastinum  and 
vertebral  column  are  encroached  upon. 

Symptoms. — Cicatricial  stenosis  causes  difficulties  of 
deglutition,  which  become  more  marked  as  the  stenosis 
increases,  and  lead  to  defective  nutrition.  The  same  signs 
are  present  in  carcinoma,  but  the  patient  shows  cachexia 


172  INDICATIONS    FOR    OPERATION    IN 

at  an  earlier  stage.  Regurgitation  of  food  is  usual,  and 
often  there  is  an  excessive  mucous  secretion.  Examination 
with  the  sound  usually  demonstrates  a  stricture,  but  not 
always  ;  pain  is  sometimes  present  independent  of  the  taking 
of  food.  (Esophagoscopy  may  directly  demonstrate  a  new 
growth.  The  normal  deglutition  bruit  is  sometimes  absent. 
In  late  stages  signs  of  the  involvement  of  other  organs  may 
appear,  and  the  supraclavicular  glands  may  be  enlarged. 
The  actual  stenosis  may  vary  if  parts  of  the  growth  slough 
from  time  to  time. 

Differential  Diagnosis. — The  true  character  of  a 
cicatricial  stricture  is  usually  revealed  by  the  history,  and 
oesophageal  cancer  produces  such  characteristic  symptoms 
that  the  diagnosis  is  seldom  in  doubt.  The  affections  which 
may  give  rise  to  difficulty  are  aortic  aneurysm,  fusiform 
dilatation  of  the  oesophagus,  and  diverticulum.  In  aneurysm 
other  and  characteristic  symptoms  are  almost  always  present, 
and  radiography  will  aid  in  diagnosis.  Any  abrupt  change 
in  the  stenosis  symptoms  is  against  cancer.  If  there  is  a 
disproportion  between  the  difficulty  in  swallowing  and  the 
difficulty  in  passing  a  bougie,  it  will  point  to  spasm.  A  slow 
development  and  the  regurgitation  of  large  quantities  of 
decomposed  food  point  to  diverticulum. 

INDICATIONS   FOR   OPERATION. 

If  a  cicatricial  stricture  is  situated  in  the  upper  part 
of  the  oesophagus,  if  it  is  annular  and  shallow  and  so 
rigid  that  it  cannot  be  dilated,  then  the  advisability  of 
total  extirpation  should  be  considered.  This  operation 
may  also  be  indicated  when  in  such  a  high  stricture  there 
are  pouches  or  kinking  above,  which  oppose  great  difficulties 
to  non-operative  measures  (H.  Starck).  According  to 
Hacker,  gastrostomy  is  advisable  in  all  cases  of  impassable 
stricture,  particularly  of  the  lower  oesophagus.  The 
time  of  choice  for  operation  is  when  it  has  been  definitely 
ascertained  that  the  body  weight  and  the  urine  secretion 
are  progressively  diminishing.  In  cicatricial  stenosis 
gastrostomy  affords  the  opportunity  of  retrograde  dilatation, 
and  one  is  only  rarely  content  with  the  simple  provision  of 
a  food  fistula. 

In  carcinoma  of  that  part  of  the  oesophagus  which  lies  in 
the    neck,    early   removal   of    the    growth   by   oesophageal 


DISEASES    OF    THE    (ESOPHAGUS.  173 

resection  is  indicated.  If  the  carcinoma  is  below,  gastros- 
tomy should  be  done.  There  is  no  general  agreement  as  to 
the  best  time  for  this  operation  ;  Hacker  advises  it  as  soon 
as  the  diflculty  in  taking  food  causes  loss  of  weight.  If  the 
carcinoma  is  high,  and  if  resection  is  impossible  and  feeding 
by  the  mouth  cannot  be  continued,  oesophagotomy  is 
advised  by  Starck,  and  the  formation  of  a  fistula  for  feeding 
purposes. 

Prognosis. — Results  of  operation. — In  cicatricial  stricture 
total  extirpation  is  a  somewhat  serious  procedure,  but 
success  has  been  obtained  in  four-fifths  of  the  cases.  The 
formation  of  a  stomach  fistula  for  the  purpose  of  dilatation 
from  below  is  very  rarely  indicated,  according  to  Starck, 
but  in  the  fifty-two  cases  reported  by  Hacker  in  which 
other  methods  had  failed,  success  was  obtained  by  this 
retrograde  dilatation. 

Resection  for  carcinoma  is  reported  by  Starck  in  eighteen 
cases  ;  five  cases  died  soon  after  operation  ;  in  the  others 
the  immediate  result  was  good,  but  none  survived  more  than 
two  years. 

QEsophagostomy  often  gives  very  good  results ;  the  patient 
puts  on  weight  and  lives  for  a  relatively  long  period.  The 
results  of  gastrostomy  are  better  the  earlier  it  is  done  ; 
frequently  it  is  noticed  that  food  passes  the  stricture  more 
easily  after  the  operation,  and  the  weight  almost  always 
increases  for  some  weeks.  The  average  period  of  life  in  66 
cases  in  the  Breslau  clinic  was  five  months. 

Risks  of  operation. — Resection  of  the  oesophagus  is  a 
serious  operation  ;  gastrostomy  relatively  free  from  risk. 
If  the  stenosis  is  low  down  below  the  aortic  arch,  and  if  there 
are  adhesions  around,  resection  is  contra-indicated,  and 
oesophagotomy  is  unsuitable. 

//  no  operation  is  done,  it  may  be  impossible  to  employ 
methods  of  dilatation,  in  which  case  the  patient  dies  from 
starvation. 

LITERATURE. 

H.  Starck.  Die  Behandlung  der  CEsophagusstenosen.  Zentralb. 
f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1902. 

Kraus.  Krankheiten  des  QEsophagus.  Nothnagel's  Handbuch 
d.  spez.   Pathol.     Bd.  xvi.     Wien,    1902. 

Hacker.  Magenoperationen  bei  Carcinom.  Wien.  klin.  Wochens. 
1895,  p.  447. 


CHAPTER     XIII. 

Diseases    of   the    Stomach. 


177 


Chapter  XIII. 
DISEASES    OF    THE    STOMACH. 

GASTRIC    ULCER. 

Etiology.— The  pathogenesis  of  gastric  ulcer  is  uncertain. 
Traumatic  lesions  of  the  mucous  membrane  do  not  lead 
to  ulcer.  Some  authors  have  stated  that  from  5  to  13  per 
cent  of  all  individuals  are  affected  with  gastric  ulcer,  but 
the  truth  of  this  is  very  questionable.  The  affection  is 
more  common  in  women  than  in  men. 

Pathological  Anatomy. — In  four-fifths  of  the  cases 
the  ulcer  is  situated  on  the  posterior  wall  near  the  pylorus. 
The  front  wall  is  affected  in  5  per  cent  only,  but  it  is  here 
that  the  perforating  ulcer  is  most  common.  According  to 
Brunner,  of  a  series  of  cases  of  perforating  ulcer  278  were 
on  the  anterior,  48  on  the  posterior  wall.  The  annular 
ulcer  is  uncommon.  The  ulcer  usually  has  a  sharply- 
marked  edge  and  may  be  crateriform  ;  sometimes  the  edge 
is  much  thickened.  If  it  extends  deeply,  it  tends  to  form 
adhesions,  which  sometimes  make  up  a  tumour-like  mass. 
If  adhesions  form,  rupture  into  the  general  peritoneal 
cavity  is  prevented  ;  adhesions  between  the  ulcer  and  the 
front  wall  of  the  abdomen  are  the  least  common.  Peri- 
gastric abscesses  may  result  from  the  penetration  of  an 
ulcer,  in  particular  left  subphrenic  abscess.  A  healing 
ulcer  may  cause  pyloric  obstruction  by  contraction  of  the 
cicatrix,  or  if  it  is  about  the  centre  of  the  stomach,  an 
hour-glass  deformity  may  be  produced  in  this  way.  In 
about  5  per  cent  of  cases  of  chronic  ulcer,  carcinoma 
supervenes. 

Clinical  Course. — The  cardinal  symptoms  of  gastric 
ulcer  are  :  Hsematemesis,  pain  shortly  after  taking  food, 
tenderness  on  pressure  in  the  stomach  area.  One  or  other 
or  all  of  these  symptoms  are  often  absent,  and  there  may 

12 


1/8  INDICATIONS    FOR    OPERATION    IN 

be  only  a  complaint  of  an  indefinite  uneasiness  in  the 
epigastrium.  There  are  often  points  tender  to  pressure 
alongside  the  lower  dorsal  vertebrae,  tarry  stools,  loss  of 
appetite,  severe  anaemia,  and  a  general  disturbance  of 
health.  Persistent  vomiting  without  hsematemesis  is  also 
common.  If  the  ulcer  is  at  the  pylorus,  signs  of  obstruction 
develop,  such  as  abnormal  peristalsis  and  contraction  of 
the  stomach  wall,  retention  of  stomach  contents,  with 
fermentative  changes  and  the  multiplication  of  sarcinge. 
The  amount  of  hydrochloric  acid  in  the  stomach  is  usually 
above  the  normal,  and  the  digestive  capacity  is  unaltered. 

If  the  margin  of  the  ulcer  is  much  indurated  it  may 
sometimes  be  felt  as  a  palpable  lump  in  the  epigastrium. 
If  perigastritis  supervenes,  a  large  swelling  is  often  to  be 
felt,  particularly  if  adhesions  are  formed  with  the  anterior 
abdominal  wall  ;  if  there  is  a  collection  of  pus  between 
the  adhesions,  there  will  be  some  pyrexia. 

Gastric  ulcer  frequently  runs  a  very  chronic  course,  the 
symptoms  often  subsiding  only  to  recur  after  a  time,  and 
the  persistent  pain  and  repeated  haemorrhages  may  reduce 
the  patient  to  a  very  low  state  of  health.  According  to 
Leube,  perforation  occurs  in  about  i  per  cent  of  cases,  but 
other  authors  (Broadbent,  Brinton,  Debove  et  Remond) 
give  a  much  higher  figure,  even  up  to  20  per  cent.  It 
seems  that  perforation,  which  is  quite  a  rarity  in  Vienna, 
is  much  more  common  in  England  and  America,  possibly 
owing  to  different  habits  of  life. 

In  one  of  my  cases  small  haemorrhages  had  frequently 
occurred ;  there  was  persistent  pain  and  tenderness  in  the 
epigastrium,  and  increasing  anaemia.  She  was  subjected 
to  a  long  course  of  medical  treatment,  and  for  a  week  the 
stomach  was  given  complete  rest,  but  the  symptoms 
persisted.  Operation  showed  slow  perforation  of  an  ulcer, 
with  adhesions';  gastro-enterostomy  cured  her  completely. 

Diagnosis. — The  diagnosis  is  easy  in  the  presence  of 
the  cardinal  symptoms  ;  if  these  are  absent  ulcer  can  for 
the  most  part  only  be  suspected.  The  most  important 
symptom  of  all  is  haematemesis.  However  carefully  the 
patient  is  examined,  it  is  usually  impossible,  according  to 
many  authors,  to  diagnose  the  position  of  an  ulcer.  Acute 
perforation  into  the  general  peritoneal  cavity  is  shown  by 
the  following  symptoms.      There   is    sudden    pain    in   the 


DISEASES    OF    THE    STOMACH.  179 

stomach  region  of  intense  severity,  the  abdomen  is  retracted, 
the  abdominal  muscles  are  board-like,  and  there  are  usually 
repeated  attempts  to  vomit.  The  patient  is  collapsed,  the 
pulse  small  and  rapid,  the  temperature  somewhat  below  the 
normal,  and  the  respirations  rapid  and  shallow.  At  the  end 
of  several  hours,  disappearance  of  the  liver  dullness  is  some- 
times to  be  made  out,  and  when  the  contraction  of  the 
abdominal  muscles  relaxes,  the  signs  of  free  fluid  in  the 
peritoneal  cavity  can  be  elicited  ;  the  pulse  becomes  fuller 
after  the  first  collapse  passes  off,  but  remains  rapid,  and  at 
the  same  time  the  temperature  usually  commences  to  rise. 

The  diagnosis  will  be  assisted  by  enquiring  for  a  previous 
history  of  epigastric  pain. 

A  patient  who  was  undergoing  a  strict  course  of  treat- 
ment for  ulcer  was  suddenly  seized  with  agonizing  abdominal 
pain,  although  at  the  time  she  was  resting  quietly  in  bed. 
Some  hours  later,  when  I  saw  her,  she  was  collapsed,  the 
abdominal  wall  was  rigid  and  tender  to  pressure,  the  liver 
dullness  absent,  and  the  pulse  very  rapid.  Operation  was 
done  three  hours  after  the  onset  of  symptoms,  and  a  small 
perforation  was  found  near  the  pylorus.  The  perforation 
was  closed  and  gastro-enterostomy  was  performed.  The 
patient  unhappily  died  four  days  later  from  peritonitis. 

Differential  Diagnosis. — It  is  often  difficult  to  diagnose 
ulcer  from  carcinoma.  The  presence  of  a  large  amount  of 
lactic  acid  and  of  long  bacilli,  the  absence  of  hydrochloric 
acid  and  sarcinse,  the  early  onset  of  stagnation  phenomena, 
diminished  digestive  capacity  of  the  gastric  juice,  and 
painless  glandular  enlargements,  point  to  cancer.  In 
hcemorrhage  from  the  stomach  due  to  hepatic  cirrhosis,  the 
spleen  is  enlarged  and  the  liver  altered. 

In  cholelithiasis  gastric  haemorrhage  is  uncommon,  but 
if  a  calculus  becomes  impacted  in  the  common  duct  it  may 
give  rise  to  a  palpable  tumour  and  symptoms  of  pyloric 
stenosis.  A  test  meal  will  show  that  the  gastric  secretion 
is  normal  in  spite  of  the  stasis,  or  there  may  be  some  excess 
of  hydrochloric  acid  ;  a  history  of  attacks  of  colic  followed 
by  jaundice  will  also  clear  up  the  diagnosis. 

In  Reichmann's  disease,  that  is  to  say  acid  hypersecretion, 
the  pain  is  usually  relieved  by  the  taking  of  food,  and  there 
is  no  trace  of  blood  either  in  the  stomach  contents  or  the 
stools. 


i8o  INDICATIONS    FOR    OPERATION    IN 

Hysterical  and  neurasthenic  conditions  are  differentiated 
by  the  irregularity  and  changeableness  of  symptoms  and 
the  absence  of  hemorrhage.  Epigastric  hernia  often 
causes  severe  gastric  symptoms,  which  may  simulate  those 
of  ulcer  ;  the  discovery  of  an  irreducible  tender  hernia  in 
the  middle  line  will  clear  up  the  cause  of  the  pains  ;  operation 
on  such  a  hernia  relieved  all  symptoms  in  a  case  which 
came  under  my  observation,  and  which  had  long  been 
looked  upon  as  one  of  gastric  ulcer.  Simple  erosions  of 
the  gastric  lining  may  cause  haemorrhage  and  other 
symptoms  in  such  a  way  as  to  be  indistinguishable  from 
ulcer. 

INDICATIONS   FOR  OPERATION. 

Leube,  one  of  the  most  experienced  and  expert  of 
clinicians,  has  formulated  the  following  indications  for 
surgical  intervention  : — 

I. — In  haemorrhage  from  the  stomach,  operation  is 
(a)  Absolutely  indicated  when  the  haemorrhages  are  small 
and  recurrent  in  spite  of  treatment,  particularly  where 
gastrectasis  coexists  ;  (b)  Not  indicated  for  a  single  pro- 
fuse haemorrhage  ;  (c)  Relatively  indicated  in  repeated 
abundant  haematemesis. 

2. — In  the  case  of  severe  pains  and  persistent  attacks 
of  vomiting,  causing  inanition,  which  do  not  yield  to  medical 
treatment,  gastro-enterostomy  is  relatively  indicated. 

3. — In  perigastritis,  gastric  adhesions,  subphrenic  and 
other  peritonitic  abscesses,  operation  is  (a)  Absolutely 
indicated  in  abscess  arising  from  ulcer,  and  in  palpable 
more  or  less  tumour-like  inflammatory  masses  in  the 
stomach  region  ;  (b)  Not  indicated,  or  only  exceptionally, 
after  failure  of  medical  treatment  when  adhesions  are  only 
suspected  and  not  palpable. 

4. — In  ulcer  perforating  into  the  peritoneal  cavity 
operation  is  absolutely  indicated  as  soon  as  possible  after 
the  first  shock  has  passed,  but  not  indicated  in  what 
has  been  vaguely  called  threatened  perforation. 

Mikulicz  has  formulated  somewhat  similar  indications. 
Surgical  treatment  of  uncomplicated  gastric  ulcer  is  indi- 
cated (a)  When  phenomena  arise  which  directly  or  indirectly 
endanger  life,  e.g.,  repeated  haemorrhages,  increasing 
emaciation,      commencing     perigastritis,     and     suspected 


DISEASES    OF    THE    STOMACH.  i8i 

carcinoma  ;  (&)  When  medical  treatment  methodically 
carried  out  gives  either  no  relief  or  only  for  a  short  period, 
and  the  pain,  vomiting,  and  dyspepsia  render  the  patient 
unfit  for  work  or  cause  a  condition  of  perpetual  suffering. 

My  own  opinion  is  in  agreement  with  these  views,  and  I 
would  say  by  way  of  summary  that  the  treatment  of  ulcer 
in  its  early  stages  belongs  almost  exclusively  to  the  physician, 
and  that  it  is  the  complications  and  the  chronic  forms  of 
the  disease  which  call  for  surgical  treatment.  It  should 
be  added  that  the  development  of  a  frequent  and  very 
important  complication  of  pyloric  ulcer — cicatricial  stenosis 
and  dilatation — is  an  absolute  indication  for  surgical 
intervention,  whether  signs  of  ulcer  are  present  or  not. 
Most  of  the  operations  performed  have  been  undertaken 
in  consequence  of  this  complication  and  for  perforation. 
Gastro-enterostomy,  pyloroplasty,  and  gastric  resection 
are  the  most  commonly  performed  operations  ;  hour-glass 
stomach  has  been  dealt  with  either  by  gastroplasty,  gastro- 
gastrostomy,  or  gastro-enterostomy. 

Contra-indications. — These  have  been  already  considered 
in  part.  It  is  not  necessary  to  operate  for  a  single  large 
haemorrhage,  nor  for  chronic  ulcer  with  hyperacidity  and 
pyloric  spasm  until  medical  treatment  has  proved  ineffectual. 

Prognosis. — Risks  and  results  of  operatiojt.  The  direct 
operative  risks  are  general  collapse  and  shock,  peritonitis, 
or  pneumonia.  In  perforated  ulcer,  operation  during  the 
first  shock  may  increase  the  latter  to  such  an  extent  as  to 
cause  death,  and  it  is  therefore  advisable  as  a  rule  to  wait 
until  this  period  has  passed.  Delay  must  never,  however, 
be  prolonged  beyond  an  hour  or  two ;  the  chances  of  recovery 
are  four  times  greater  during  the  first  twelve  hours  than 
later.  Of  377  cases  of  perforated  gastric  ulcer  collected 
by  Brunner,  201  (52  per  cent)  recovered  after  operation, 
but  his  estimate  that  of  all  cases  operated  on  at  least  two- 
thirds  die,  and  at  the  highest  one-third  recover,  is  un- 
doubtedly correct.  The  mortality  of  those  operated  on 
during  the  first  twelve  hours  is  about  25  per  cent. 

It  is  a  striking  fact  that  both  after  a  general  anaes- 
thetic and  after  local  anaesthesia,  cases  of  laparotomy  not 
infrequently  develop  pneumonia,  sometimes  of  a  fatal 
type. 

Operative  peritonitis  is  rarer,  and  tends  to  become  more 


i82  INDICATIONS    FOR    OPERATION    IN 

and  more  infrequent.  Of  all  cases  of  operation  on  the 
stomach  in  the  Wurzburg  clinic,  2  per  cent  died  from  this 
complication,  so  that  it  is  not  altogether  negligible. 

The  operative  risk  varies  with  the  nature  of  the  operation 
and  the  surgeon.  Mayo  Robson  records  165  recoveries  in 
177  cases,  and  of  eight  cases  of  perforating  ulcer  of  the 
stomach  on  which  he  operated,  two  died.  The  cases  of 
resection  gave  the  highest  mortality  (27 "8  per  cent). 
According  to  Mikulicz  the  mortality  of  gastro-enterostomy 
is  16  per  cent,  that  of  pyloroplasty  13  per  cent. 

The  latter  operations  are  therefore  generally  preferable 
to  resection,  but  each  method  has  its  particular  indications  ; 
for  example,  if  an  ulcer  is  situated  on  the  anterior  wall 
resection  may  be  technically  easy,  and  therefore  advisable. 
A  complication  which  occurs  after  gastro-enterostomy  is 
regurgitant  vomiting,  but  this  is  to  be  avoided  by  proper 
operative  technique  and  the  prevention  of  any  spur  or 
kink  preventing  the  onward  passage  of  the  jejunal  contents. 

In  cases  of  pyloric  obstruction,  when  operation  is 
successful,  the  motor  and  secretory  functions  of  the  stomach 
return  to  the  normal  in  the  course  of  a  few  months,  the 
haemorrhages  which  had  resisted  medical  treatment  cease, 
and  the  patient  loses  his  sense  of  discomfort  and  pain.  A 
recurrence  of  obstructive  signs  after  operation  sometimes 
takes  place,  but  is  rare,  as  is  also  a  reappearance  of  signs 
of  ulcer ;  Neumann  has,  however,  collected  eight  cases 
of  peptic  ulcer  after  gastro-enterostomy,  four  of  which 
succumbed  to  perforation.  The  end  results  of  operation 
are  also  good  ;  Mikulicz  records  48  permanent  recoveries 
in  54  cases  of  ulcer  and  pyloric  stenosis  ;  the  best  results 
were  obtained  by  gastro-enterostomy. 

Without  operation. — The  great  majority  of  cases  of  gastric 
ulcer  recover  under  careful  medical  treatment.  Leube 
records,  among  424  of  his  patients,  rapid  and  permanent 
recovery  in  74  per  cent  after  four  to  five  weeks'  treatment, 
improvement  in  22  per  cent,  no  improvement  in  16  per 
cent.  The  percentage  mortality  was  2*4  per  cent.  This 
low  mortality  corresponds  with  my  own  experience.  The 
figures  given  by  some  French  (Doyen)  and  English  (Barling) 
surgeons,  viz.,  10  per  cent  to  50  per  cent,  are  in  my  opinion 
much  too  high.  A  repetition  of  the  course  of  treatment 
completes  recovery  in   a  large  proportion   of  those  cases 


DISEASES    OF    THE    STOMACH.  183 

which  are  at  first  only  improved.  If  gastric  ulcer  is 
untreated,  the  mortality  on  the  other  hand  reaches  about  10 
per  cent  ;  of  these  6  to  7  per  cent  succumb  to  perforation, 
3  to  5  per  cent  to  a  profuse  haemorrhage. 

According  to  Gerhardt,  cicatricial  stenosis  of  the  pylorus 
occurs  in  about  10  per  cent,  and  this  if  untreated  by  operation 
will  probably  prove  fatal. 

When  ulcer  persists  for  a  long  period,  it  not  infrequently 
is  the  starting  point  of  carcinoma. 

If  not  operated  on,  about  95  per  cent  of  cases  of  perfora- 
tion die,  50  per  cent  during  the  first  twenty-four  hours  after 
the  accident  ;  the  few  cases  which  recover  are  those  in 
which  the  stomach  was  empty  at  the  time  of  perforation. 

LITERATURE. 

F.  Gross  et  G.  Gross.  Perforation  de  I'Estomac  par  Ulcere. 
Rev.  de  Chirurg.     Paris,  1904. 

RoBsoN.  Lecture  on  the  Complications  of  Gastric  Ulcer.  Brit. 
Med.  Jour.,  Vol.  I,  1901,  p.  257. 

KoRTE.  Ueber  die  chirurgische  Behandlung  des  Magengesch- 
wiirs  und  seiner  Folgezustande.     Arch.  f.  klin.  Chir.    Bd.  Ixiii. 

Brunner.  Das  akut  in  die  freie  Bauchbohle  perforierende 
Magengeschwiir.     Deut.  zeit.  f.  Chir.     Bd.  Ixix,  p.  106. 

Finney.  Perforated  Ulcer  of  the  Stomach.  Annals  of  Surgery, 
1900,  Vol.  33. 

Terrier  et  Hartmann.     Chirurgie  de  I'Estomac,  1899. 

V.  Mikulicz.  Die  chirurgische  Behandlung  des  chronischen 
Magengeschwiirs.  Mitteil.  a.  d.  Grenzgebieten  d.  Med.  u.  Chir. 
Bd.  ii. 

Leube.  Erfolge  der  internen  Behandlung  des  peptischen 
Magengeschwiirs.     Ibidem. 

Rencki.  Ueber  die  funktionellen  Ergebnisse  nach  Operationen 
am  Magen  bei  Ulcus  und  gutartiger  Pylorusstenose.  Ibid.  Bd. 
viii.     Hft.  3. 

Lincner  lind  Kuttner.  Die  Chirurgie  des  Magens  und  ihre 
Indikationen.     Berlin,  1898. 

T^.neffi.     Resezione     dello     Stomacho     per     Ulcera     Gastrica. 
Supplem.  al  Policlinico,  No.  12,  1902. 


CARCINOMA    OF    THE    STOMACH. 

Pathological  Anatomy. — The  commonest  site  of 
carcinoma  of  the  stomach  is  in  the  neighbourhood  of  the 
pylorus  (30  per  cent),  then  on  the  greater  and  lesser 
curvatures  (together  30  per  cent).  In  more  than  70  per 
cent  the  growth  is  of  the  scirrhous  type  ;  the  medullary  and 


i84  INDICATIONS    FOR    OPERATION    IN 

colloid  types  grow  rapidly  and  ulcerate  early.  Cancer 
often  develops  on  the  site  of  an  old  ulcer  ;  it  is  almost 
always  a  primary  growth  ;  the  softer  growths  are  the 
earliest  to  form  metastases.  Cancer  at  the  cardiac  orifice 
shows  no  tendency  to  invade  the  oesophagus,  and  pyloric 
cancer  does  not  extend  to  the  duodenum. 

Clinical  Course. — The  disease  usually  begins  insidi- 
ously. In  some  cases  there  are  only  general  symptoms  : 
weakness,  rapid  wasting,  anaemia,  loss  of  appetite,  and 
distaste  for  food.  The  most  important  of  the  stomach 
symptoms  are  regurgitation  and  vomiting  of  stomach 
contents,  often  acid  in  taste,  vomiting  of  mucus  and  coffee- 
ground  masses,  pain  in  the  epigastrium,  particularly  after 
eating,  and  tenderness  in  the  epigastrium.  The  most 
important  sign  is  the  presence  of  an  epigastric  tumour. 
This  may  move  with  respiration,  but  can  then  be  fixed  in 
the  situation  where  it  lies  on  expiration.  In  pyloric  cancer, 
symptoms  of  gastric  dilatation  are  often  present,  the 
stomach  contents  are  retained  long  after  a  meal,  there  is 
vomiting  of  large  quantities,  and  often  excessive  peristalsis. 

Examination  of  the  stomach  contents  shows  absence  or 
diminution  of  hydrochloric  acid,  defective  capacity  of 
peptic  digestion,  and  later  the  presence  of  lactic  acid  and 
other  stagnation  products,  even  when  there  is  no  pyloric 
stenosis.  Numbers  of  long  bacilli  and  blood  pigment 
material  are  also  often  present.  The  normal  leucocytosis 
of  digestion  is  absent. 

Metastases  may  be  clinically  recognizable  before  the 
primary  tumour,  particularly  glandular  metastases  above 
the  left  clavicle.  The  development  of  ascites  is  almost 
always  a  sign  of  the  presence  of  metastases  in  the  perito- 
neum or  the  glands  of  the  portal  fissure. 

In  the  later  stages  fever  and  cachexia  make  their 
appearance. 

Diagnosis. — A  palpable  tumour  is  the  most  valuable 
sign,  but  the  presence  of  the  above-mentioned  secretion- 
anomalies,  along  with  retention  of  stomach  contents  and 
numbers  of  long  bacilli,  is  sufficient  for  a  fairly  confident 
diagnosis,  and  it  becomes  more  certain  if  repeated  examina- 
tion shows  that  these  signs  are  constant  and  persistent. 

In  cancer  of  the  cardiac  orifice,  the  symptoms  may  be 
those  of  oesophageal  obstruction,  obstruction  to  the  passage 


DISEASES    OF    THE    STOMACH.  185 

of  solid  food,  delay  or  absence  of  the  second  bruit  of 
deglutition,  and  the  sound  may  demonstrate  stenosis. 
Pain  is  then  most  common  at  the  xiphisternum.  The 
tumour  may  be  visible  with  the  oesophagoscope,  but  it 
remains  impalpable  until  the  latest  stages. 

The  carcinomatous  ulcer  usually  presents  the  character- 
istic ulcer  history.  When  repeated  examinations  at  short 
intervals  demonstrate  a  change  in  the  gastric  chemistry, 
hyperchlorhydria  first  disappearing  and  then  giving  place 
to  hypochlorhydria,  increase  in  lactic  acid,  decreased 
capacity  for  peptic  digestion,  multiplication  of  long  bacilli 
and  stagnation  phenomena,  then  the  diagnosis  will  be 
carcinoma  developed  from  a  chronic  gastric  ulcer. 

In  a  patient  fifty  years  of  age  the  history  pointed  to  gastric 
ulcer  of  some  years'  standing.  For  six  months  pain  had 
developed  anew  after  food,  vomiting  had  been  frequent, 
and  there  was  loss  of  flesh,  melsena,  and  great  tenderness  on 
pressure  over  the  stomach.  Tenderness  was  also  marked 
on  pressure  in  the  neighbourhood  of  the  lower  dorsal 
vertebrae.  Examination  of  the  stomach  contents  showed 
at  first  a  high  degree  of  hyperchlorhydria,  which  later 
gradually  gave  place  to  a  normal  amount  of  hydrochloric 
acid,  associated  with  the  appearance  of  lactic  acid  and 
signs  of  retention  of  stomach  contents.  Laparotomy 
showed  a  carcinoma  on  the  posterior  stomach  wall  developed 
on  the  site  of  an  old  ulcer.  Gastro-enterostomy  was 
performed,  but  death  occurred  some  days  later. 

In  pyloric  cancer  the  signs  of  pyloric  stenosis  are  clinically 
the  most  prominent.  Lactic  and  butyric  acid  are  especially 
abundant ;  the  tumour  is  palpable  comparatively  early. 
In  regard  to  differential  diagnosis,  there  are  many  con- 
ditions which  have  to  be  considered.  Chronic  ulcer  is 
associated  with  increased  amount  of  hydrochloric  acid, 
and  lactic  acid  is  not  present.  Kinking  by  adhesions  to 
the  gall-bladder,  etc.,  is  not  associated  with  any  particu- 
lar change  in  the  chemistry  of  the  secretion.  Atonic 
inefficiency  is  not  associated  with  tumour  or  with  abnormal 
peristalsis. 

In  atrophy  of  the  gastric  mucous  membrane  there  is  no 
palpable  tumour,  examination  of  the  blood  shows  the 
changes  of  progressive  pernicious  auccmia,  and  there  is  no 
bIor)d  in  the  gastric  contents. 


i86  INDICATIONS    FOR    OPERATION    IN 

The  alterations  in  the  gastric  secretion  are  also  of  valiie 
in  excluding  tumours  of  the  gall-bladder,  omentum, 
intestine,  and  pancreas.  Renal  tumours  bulge  into  the 
loin  and  lie  behind  the  colon. 

Chronic  gastric  catarrh  does  not  provoke  any  grave 
alteration  in  health  ;  the  amount  of  hydrochloric  acid 
varies,  and  improvement  and  changes  for  the  worse  alternate. 
The  secretion  of  mucus  is  generally  excessive ;  if  this 
decreases  one  will  usually  note  improvement  in  the  secretory 
functions. 

INDICATIONS  FOR  OPERATION. 

All  authors  agree  that  when  carcinoma  is  diagnosed  at 
an  early  stage  operation  is  absolutely  indicated.  Un- 
fortunately at  this  stage  diagnosis  is  attended  with  great 
difficulties,  and  usually  no  positive  opinion  is  arrived  at 
until  a  palpable  tumour  appears.  When  this  stage  is 
reached  the  disease  has  usually  made  considerable  progress. 

For  this  reason  there  are  certain  signs  and  conditions 
which  constitute  absolute  indications  for  operation, 
although  the  diagnosis  of  cancer  may  be  uncertain. 
Operation  is  called  for  (i)  When  the  signs  point  definitely 
to  progressive  stenosis  of  the  pylorus,  and  the  other  signs 
point  to  cancer,   although  there  is  no   palpable  tumour  ; 

(2)  When  a  palpable  tumour  is  present  which  is  apparently 
without  adhesions  to  the  surrounding  parts  and  has  not 
produced    recognizable      metastases      in      other     organs  ; 

(3)  When  there  is  marked  interference  with  the  motor 
function,  even  when  the  tumour  is  not  at  the  pylorus  and 
adhesions  cannot  be  excluded,  if  vomiting  and  motor 
insufficiency  are  producing  inanition. 

Opinions  differ  as  to  the  advisability  of  exploratory 
laparotomies.  According  to  what  has  just  been  said  it  is 
clear  that  many  operations  are  bound  to  be  exploratory 
in  the  first  instance,  to  be  followed  by  a  radical  procedure 
under  favourable  circumstances.  Kuttner  is  of  opinion 
that  exploratory  laparotomy  ought  to  be  considered  if 
the  symptoms  as  a  whole  suggest  cancer,  and  there  is 
reason  to  think  that  it  may  be  possible  to  remove  the 
growth,  particularly  if  there  are  definite  signs  of  stenosis. 
Ringel  agrees  with  Kummel  that  if  there  is  a  definite 
suspicion  of  cancer  the  abdomen  should  be  opened. 


DISEASES    OF    THE    STOMACH.  187 

My  own  view  is  that  exploratory  laparotomy  should  be 
undertaken  in  all  cases  where  the  clinical  phenomena 
suggest  the  development  of  cancer  on  the  site  of  a  chronic 
ulcer,  even  when  no  tumour  is  to  be  felt  and  symptoms  of 
pyloric  stenosis  are  absent. 

The  operations  that  may  be  performed  are  : — 

1.  Resection,  the  radical  operation  by  which  alone 
complete  recovery  is  obtainable. 

2.  Gastro-enterostomy,  to  be  employed  when  the  tumour 
cannot  be  extirpated,  when  there  is  marked  gastric 
inefficiency,  and  there  is  some  hope  of  prolonging  life  for 
a  considerable  period. 

3.  Gastrostomy,  in  cancer  of  the  cardia,  to  feed  the 
patient  and  avoid  the  irritant  effect  of  food  passing  over 
the  seat  of  disease.  Whether  resection  or  gastro- 
enterostomy is  advisable  in  any  given  case  it  is  not  as  a 
rule  possible  to  say  until  the  stomach  has  been  opened 
and  the  extent  of  the  disease  explored. 

Contra-indications. — With  the  following  opinion  of 
Mikulicz  I  entirely  agree.  He  says :  "  When  the  result  of 
palpation  is  negative,  and  there  are  no  motor  disturbances, 
operation  is  inadvisable,  at  least  for  the  time  being,  even 
if  all  other  signs  point  to  cancer.  Only  a  radical  operation 
will  be  considered  under  such  circumstances,  and  experience 
has  shown  that  a  stomach  cancer  which  has  already  caused 
definite  clinical  symptoms,  and  yet  is  not  palpable,  is 
almost  always  so  situated  as  to  be  inaccessible  for  radical 
removal." 

■Emphysema,  chronic  bronchitis  and  tuberculosis  of  the 
lungs,  if  of  a  pronounced  type,  contra-indicate  operation, 
and  the  same  is  to  be  said  of  advanced  atheroma,  uncom- 
pensated heart  disease,  and  any  other  serious  organic  lesion. 

The  presence  of  metastases,  particularly  in  the  liver,  and 
of  carcinomatous  peritonitis,  contra-indicate  intervention. 

Prognosis. — Results  of  operation.  It  is  difficult  to 
formulate  any  definite  prognosis  of  operation ;  the  results 
vary  much  in  the  different  tables  given ;  some  surgeons 
operate  on  cases  which  others  would  refuse,  and  the  same 
surgeon  obtains  different  results  at  different  stages  of 
his  experience  and  with  different  methods.  The  immediate 
operation  results  show  recovery  in  at  the  most  75  per 
cent,  and  on  an  average  about  a  half  or  less  get  over  the 


i88  INDICATIONS    FOR    OPERATION    IN 

operation.  The  mortality  among  56  cases  in  Mikulicz' 
hands  was  46-5  per  cent,  in  the  next  44  cases  25  per  cent. 

Nine  out  of  twenty-four  in  Czerny's  clinic  died  from  the 
operation  (38  per  cent),  17  out  of  25  in  Rydygier's  clinic 
(68  per  cent).  Kronlein  reports  an  operative  mortality 
of  28  per  cent  in  50  resections,  Kappeler  26  per  cent  in 
30  cases,  Ringel  59-4  per  cent  in  63  cases,  Roux  33  per  cent 
in  39  cases.  The  Mayos  report  5  deaths  in  20  cases  in  a 
first  series,  i  death  out  of  15  in  a  second  series. 

The  operative  mortality  is  therefore  high,  though  it 
varies  considerably  ;  approximately  a  quarter  die.  The 
causes  of  death  are  shock,  pneumonia,  pulmonary  embolism, 
cardiac  failure,  peritonitis.  The  risks  of  gastro-enterostomy 
in  cancer  are  also  high.  Of  82  cases  reported  by  Ringel, 
62  per  cent  died  from  shock,  pneumonia,  peritonitis, 
pulmonary  embolism,  or  cachexia.  Of  96  patients  in  Roux's 
clinic,  28  per  cent  succumbed,  7  from  general  weakness, 
5  from  pulmonary  complications,  4  from  cardiac  failure, 
4  from  faulty  technique,  3  from  peritonitis,  etc. 

The  end  results  of  resection  are  comparatively  good, 
considering  that  the  disease  is  inevitably  fatal  without 
operation,  but  recurrence  is  the  rule.  The  results  in  58 
of  Mikulicz'  cases  who  survived  the  operation  are  as  follows  : 
17  alive  more  than  a  year,  10  more  than  2  years,  and  4 
more  than  3^  years  after  the  operation.  The  average 
duration  of  life  of  the  cases  who  died  from  recurrence  was 
more  than  16  months. 

Wolfler  has  recorded  several  cases  alive  some  years  after 
operation ;  14  survived  4  years,  4  more  than  5  years,  and 
2  longer  than  this. 

The  average  duration  of  life  in  the  cases  reported  by 
Kolbe  from  Roux's  clinic  was  at  the  time  of  publication 
three  years  and  eight  months,  the  oldest  being  nine  years 
and  four  months.  The  length  of  life  in  12  cases  which 
had  died  was  on   an   average  two  years  and  two  months. 

Gastro-enterostomy  also  increases  the  average  duration  of 
life,  but  not  to  so  marked  an  extent  as  gastrectomy.  Of 
67  patients  operated  on  in  Mikulicz's  clinic  who  survived  the 
operation,  2  only  lived  more  than  2  years,  10  more  than 
I  year,  11  more  than  six  months,  and  the  remaining  44 
less  than  six  months.  The  average  duration  of  life  after 
operation    was    6"4    months.     Ringel's    figures    give    the 


DISEASES    OF    THE    STOMACH.  189 

average  post-operative  survival  as  six  and  a  half  months. 
In  a  few  cases  patients  have  lived  three  years  or  more 
(Stendel-Czerny,  Alsberg,  Strauss)  ;  a  patient  under  my 
own  observation  survived  more  than  two  years  and  a  half. 

These  various  statistics  show  that  operative  interference 
of  whatever  kind  is  attended  with  a  high  degree  of 
immediate  risk  in  gastric  cancer,  but  that  nevertheless  it 
is  often  proper  to  recommend  it  in  the  hope  of  permanent 
cure  in  some  cases,  in  others  for  the  relief  of  distressing 
symptoms  and  for  the  prolongation  of  life. 

The  general  condition  is  often  remarkably  good  after 
resection ;  the  patient  puts  on  weight  and  regains  appetite. 
Slight  epigastric  uneasiness  often  persists,  and  there  may 
be  distaste  for  flesh  foods.  In  some  cases  the  anaemia 
persists  for  a  long  time.  The  stomach  often  regains  its 
normal  motility,  according  to  Mikulicz,  and  sometimes 
this  even  surpasses  the  normal.  The  gastric  secretion 
does  not  as  a  rule  return  to  the  natural  state,  but  sometimes 
free  hydrochloric  acid  reappears  ;  the  production  of  lactic 
acid  on  the  other  hand  tends  to  persist  for  a  long  time. 

The  effect  of  gastro-enterostomy  is  much  less  striking. 
I  have  indeed  seen  cases  who  improved  for  a  time  and  put 
on  weight,  but  after  a  short  period  they  commenced  to  go 
down  hill  and  rapidly  succumbed.  In  the  majority  of 
cases  the  general  condition  is  little  changed,  and  the 
marasmus  remains.  Some  symptoms,  however,  vomiting 
and  foetid  eructations,  are  often  greatly  relieved,  and  in 
cases  of  pyloric  obstruction  the  pains  due  to  spasmodic 
contractions  of  the  stomach  are  eliminated. 

Without  operation. — When  there  is  no  pyloric  obstruction, 
the  general  symptoms,  weakness,  anaemia,  etc.,  are  the 
most  prominent.  Patients  usually  succumb  with  symptoms 
of  heart  failure  ;  in  other  cases  they  die  from  septicaemia. 
If  there  is  pyloric  obstruction,  the  disease  runs  a  rapid 
course,  and  the  repeated  vomiting  of  the  stagnant  stomach 
contents  quickly  exhausts  the  strength.  My  experience, 
however,  agrees  with  that  of  others  who  have  recorded 
improvement,  and  even  increase  of  weight  in  some  cases 
in  which  the  stomach  has  been  regularly  washed  out.  In 
ulcerating  carcinoma,  haemorrhages  and  fever  complicate 
the  history,  and  once  metastases  form  the  progress  of  the 
disease  is  very  rapid. 


I90  INDICATIONS    FOR    OPERATION    IN 

According  to  Kronlein,  cancer  of  the  stomach  without 
surgical  treatment  terminates  fatally  in  about  a  year ; 
Riegel  places  the  average  period  between  one  and  two 
years.  When  the  carcinoma  causes  pyloric  stenosis,  the 
course  of  the  disease  is  often  very  short.  I  have  seen  death 
supervene  in  a  few  weeks  after  the  onset  of  the  first  clinical 
svmptoms. 

LITERATURE. 

RiNSEL.  Die  Resultate  der  operativen  Behandlung  des 
Magencarcinoms.     Beitr.  z.  klin.  Chir.     Bd.  xxxviii. 

Mikulicz  and  Kausch.  "  INIagencarcinom  "  in  Handbuch  d. 
prakt.  Chir.  Bergmann,  ^Mikulicz,  u.  Bruns.  Bd.  iii.  2nd  ed., 
1903. 

Kronlein.  Die  bisherigen  Erfahrungen  bei  der  Radikalen 
Operationen   des   [Magencarcinoms.     Arch   f.  khn.   Chir.,    Bd.  Ivii. 

Riegel.  Die  Krankheiten  des  INIagens.  2nd  Ed.  Nothnagel's 
Handbuch  d.  spez.  Pathol,  u.  Therap. 

Terrier  at  Hartm.ann.     Chirurg.  de  TEstomac.     Paris,  1899. 

MoRiscN.  After  Progress  of  Five  Cases  of  Partial  Gastrectomy 
for  Cancer.     Lancet,  Jan.  11,  1902. 

Syme.  Gastrectomy  for  Carcinoma  of  the  Pylorus.  Lancet, 
Sept.  13,  1902. 

CuMSTON.  The  Indications  for  Operation  in  Malignant  Neoplasms 
of  the  Stomach.     Boston  Med.  and  Surg.   Jour.,   Sept.  5,  1901. 

ScHiFF.  Die  Diagnose  des  Magencarcinoms.  Centralb.  f.  d. 
Grenzgebiete  d.  Med.  u.  Chir.,  1898. 

Mathieu.    Maladies  de  I'Estomac.    Pari?.  ,  1901. 

SouPAULT  et  Hartmann.  Resultats  Eloignes  de  la  Gastro- 
enterostomy.    Rev.  de  Chir.,  1899. 

Gluzinski.  Friihdiagnose  des  Magencarcinoms  und  Aussichten 
der  ladikal  Operation.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
Bd.  V. 

Lindner  und  Kuttner.  Die  Chirurgie  des  Magens  und  ihre 
Indikationen.     Berlin.      1898. 

GozEL.  Le  Traitement  du  Cancer  de  I'Estomac  par  la  Gastro- 
entero-anastomose.     Rev.  de  Chir.,  Feb.,  if;o4. 

KoLBE.  Le  Cancer  de  I'Estomac  et  son  Traitment  Chirurgical. 
Lausanne:   Borgeand.      1901. 

Ferrari.  Contributo  alio  Studio  della  Pathologia  di  Ventriculo. 
Clinica  Chirurgica,  10,  1902. 

Ceccherelli.  Sulla  Chirurgia  Gastrica.  Alti  del  x  Congresso 
Medico  dell'  Alta  Italia.     Mantova.     1902. 


SIMPLE   TUMOURS  AND   FOREIGN-BODY   TUMOURS  OF 
THE    STOMACH. 

Etiology. — The  foreign-body  tumours    of  the  stomach 
occur  from  the  habitual  eating  of  hair  or  vegetable  fibre, 


DISEASES    OF    THE    STOMACH.  191 

or  gelatin-containing  fluid.  They  are  found  most 
commonly  in  women,  and  relatively  frequently  in  young 
girls.  The  simple,  true  growths  of  the  stomach  (myoma) 
may  occur  at  any  age. 

Pathological  Anatomy. — The  foreign-body  masses 
are  often  freely  movable  in  the  stomach  ;  when  of  large 
size  they  may  have  the  shape  of  a  complete  cast  of  the 
stomach,  as  in  a  case  recorded  by  myself.  Ulceration  and 
perforation,  with  consequent  peritonitis,  are  typical  results. 

The  simple  new  growths  are  uncommon  ;  usually  they 
are  myomata,  and  may  attain  a  large  size,  protruding  more 
frequently  into  the  peritoneal  cavity  than  into  the  stomach. 
In  two  cases  I  have  seen  transformation  into  sarcoma. 

Clinical  Course. — Foreign-body  masses  can  often  be 
recognized  by  palpation.  At  first  they  are  freely  movable, 
and  at  this  stage  the  stomach  symptoms  are  slight,  but 
later  vomiting  becomes  uncontrollable,  with  pain  in  the 
epigastrium  and  signs  of  peritoneal  irritation.  After  several 
years  they  may  cause  perforation  and  peritonitis. 

The  true  simple  growths  are  also  compatible  with  long  life. 
The  secretory  functions  of  the  stomach  are  little  interfered 
with,  and  whether  or  not  its  motor  functions  are  embarrassed 
depends  on  the  site  and  attachments  of  the  tumour. 

Diagnosis. — A  positive  diagnosis  is  only  exceptionally 
arrived  at  in  the  case  of  the  foreign-body  masses.  A 
history  of  long  ingestion  of  hair  or  vegetable  fibre  in  a 
young  individual,  free  mobility  of  the  swelling,  which  is 
shown  by  inflation  to  belong  to  the  stomach,  and  in 
particular  the  discovery  of  hair  in  the  fcEces,  will  point  to 
the  true  nature  of  the  case.  Incorrect  diagnoses  of  stomach 
cancer,  movable  kidney,  splenic  tumour,  and  renal  tumour 
have  been  made. 

A  tumour  of  the  stomach  which  has  been  known  to  have 
been  slowly  growing  for  some  years,  is  probably  of  a  simple 
nature ;  the  general  condition  will  be  good,  and  the  functions 
of  the  stomach  normal.  A  correct  diagnosis  is  rarely  made, 
the  condition  being  usually  taken  for  carcinoma. 

INDICATIONS   FOR  OPERATION. 

If  a  tumour  is  found  in  the  stomach  region,  and  there  is 
even  a  suspicion  of  its  being  a  hair  ball  or  similar  mass, 
an   operation  slioiild  be  advised,   and  signs  of  peritoneal 


192  INDICATIONS    FOR    OPERATION    IN 

irritation  point  to  its  being  urgently  necessary.  Perforation 
is  of  course  an  absolute  indication  for  intervention.  The 
foreign  body  will  be  removed  by  gastrotomy,  the  stomach 
being  then  closed.  Benign  new  growths  also  call  for 
extirpation  and  partial  resection  of  the  stomach  ;  the 
fact  that  these  growths  sometimes  become  malignant 
makes  their  removal  necessary,  even  though  they  may  be 
causing  little  inconvenience.  The  only  contra-indication 
to  operation  is  the  presence  of  some  condition  which  renders 
abdominal  section  a  risky  proceeding. 

Prognosis. — Results  of  operation.  All  the  cases  of 
operation  for  hair  ball  which  were  collected  by  Schopf, 
nine  in  number,  were  successful.  Since  the  appearance 
of  his  paper  further  successes  have  been  recorded.  Opera- 
tion for  myoma  is  a  more  serious  undertaking,  as  it  involves 
partial  gastrectomy. 

Withotit  operation. — Hair  balls  and  other  similar  masses 
relatively  often  cause  pressure  necrosis  of  the  stomach  wall 
and  fatal  peritonitis.  A  myoma  may  undergo  sarcomatous 
transformation.  If  pedunculated  it  may  become  strangu- 
lated by  torsion  of  the  pedicle,  and  in  this  way  cause 
danger  to  life. 

LITERATURE. 

Steiner.  Myome  des  Magen-Darmkanals.  Beitr.  z.  klin. 
Chir.,  Bd.  xxii. 

F.  Schopf.  Ein  Trichobezoar  im  Magen.  Wien.  klin.  Wochen., 
p.  1 145,  1899. 

W.  AF  ScHULTEN.  Uebct  Haargeschwiilste  un  Magen.  Mitteil. 
a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ii. 

Gemmel.     Foreign  Bodies  in  Ihe  Stomach.     Lancet,  Vol.  ii.  1899. 

BoRRMANX.  Ueber  Netz-  und  Pseudo-Netztumoren  nebst 
Bemerkungen  iiber  Myome  des  Magens.  Mitteil.  a.  d.  Grenzgebiete 
d.  Med.  u.  Chir.     Bd.  vi. 

Cernerri.     Sui  leiomiomi  dello  Stomaco.   II  Morgagni,  No.  3,  1903. 

Caminiti.  Myome  du  Pylore,  Gazette  Hebdomadaire,  No. 
89,  1901. 

KoEPPELiN.  Corps  Etranger  de  I'Estomac.  Lyon  Medical, 
No.  30,  1 90 1,  p.  121. 


PYLORIC    STENOSIS,    GASTRIC     DILATATION,    AND 
HOUR-GLASS    STOMACH. 

Pathological  Anatomy. — Stenosis  of  the  pylorus  may 
arise  from  a  variety  of  causes.     In  some  cases  it  follows 


DISEASES    OF    THE    STOMACH.  193 

carcinoma  or  the  cicatrization  of  an  ulcer  ;  in  others 
adhesions  cause  kinking,  or  the  outlet  is  compressed  from 
without  or  blocked  by  a  gall-stone.  Clinically  the  stenoses 
in  the  neighbourhood,  as  far  as  the  papilla  of  Vater,  may 
be  classed  with  the  stenoses  of  the  actual  pylorus.  In  a 
group  of  cases  the  obstruction  is  due  to  pyloric  spasm. 
When  pyloric  stenosis  has  been  present  for  some  time, 
the  stomach  becomes  secondarily  dilated  and  the  muscular 
wall  hypertrophied. 

Hour-glass  stomach  is  usually  caused  by  the  cicatrization 
of  an  ulcer  of  the  body  of  the  stomach,  more  rarely  by 
carcinoma  or  adhesions. 

Clinical  Course. — Certain  symptoms  are  common  to 
stenosis,  however  caused  ;  others  vary  according  to  the 
original  lesion.  In  all  cases  there  is  a  sensation  of  fullness 
in  the  stomach  region,  and  usually  loss  of  appetite  and 
eructations.  Vomiting  is  hardly  ever  absent,  and  the 
motor  functions  of  the  stomach  are  altered. 

In  the  slighter  forms  (motor  inefficiency  of  the  first 
degree)  there  is  long  delay  in  emptying  the  stomach,  but 
by  the  early  morning  the  organ  has  passed  on  its  contents 
and  is  empty. 

In  motor  inefficiency  of  the  second  degree  there  is  always 
food  material  in  the  stomach  ;  splashing  can  be  elicited  over 
a  wide  area,  and  many  hours  after  a  meal.  When  the 
stomach  is  inflated,  it  is  seen  that  it  extends  abnormally 
low.  If  the  patient  is  given  salol,  the  elimination  of 
salicylic  acid  and  phenic  acid  in  the  urine  persists  for  an 
abnormally  long  time. 

Very  often,  particularly  when  the  condition  is  advanced, 
a  very  pronounced  peristalsis  can  be  seen  and  felt  passing 
from  left  to  right ;  these  tetanic  contractions  are  painful, 
and  as  the  wave  passes  the  wall  becomes  consecutively 
contracted  and  relaxed. 

The  state  of  the  gastric  secretion  depends  on  the  nature 
of  the  causal  condition.  When  there  is  hyperacidity  the 
total  amount  withdrawn  with  the  stomach  tube  is  often  con- 
siderably greater  than  that  which  the  patient  had  swallowed. 
Almost  always  sarcinse  are  present  when  hydrochloric  acid 
is  present,  and  lactic  acid  when  hydrochloric  acid  is  absent. 
A  diminution  of  hydrochloric  acid  runs  parallel  with  a 
diminution   of  sarcin^e  ;    when   the  amount  of  lactic   acid 

13 


194  INDICATIOXS    FOR    OPERATION    IN 

is  large  the  long  bacilli  are  numerous  and  the  sarcinse  few. 
The  amount  of  urine  secreted  is  usually  small,  and  decreases 
as  the  stenosis  becomes  more  pronounced  ;  the  patient 
complains  much  of  thirst,  and  is  constipated.  Generalized 
tetany,  involving  the  muscles  of  the  trunk,  diaphragm,  and 
larynx,  may  be  the  cause  of  death. 

Diagnosis. — The  presence  of  motor  inefliciency  and 
stagnation  of  gastric  contents  will  lead  to  a  diagnosis  of 
pyloric  obstruction.  When  remains  of  food  are  found  in 
the  stomach  many  hours  after  a  meal,  and  there  is  abnormal 
peristalsis,  the  diagnosis  is  quite  clear,  but  the  cause  can 
only  be  determined  by  careful  examination  into  the 
chemistry  of  the  stomach,  the  history,  and  the  other 
symptoms. 

Hour-glass  stomach  can  sometimes  be  diagnosed  by 
inflation.  In  some  cases,  on  pressure  at  the  cardiac  end, 
the  contents  can  be  made  to  pass  with  a  rush  through  the 
stricture.  The  presence  of  marked  and  painful  peristalsis 
is  against  simple  atonic  dilatation,  this  symptom  being 
usually  absent  in  the  latter. 

Spasmodic  stenosis  of  the  pylorus  does  not  seem  to  often 
cause  marked  motor  inefficiency  ;  if  the  latter  is  present, 
it  is  not  possible  to  differentiate  between  spasmodic  and 
anatomical  stenosis. 

INDICATIONS   FOR  OPERATION. 

If  there  are  definite  signs  of  stenosis,  but  the  motor 
inefficiency  is  of  the  first  degree  only,  operative  interference 
is  in  general  only  indicated  when  new  growth  is  suspected. 
If,  however,  in  the  presence  of  motor  inefficiency  of  the 
first  degree,  the  patient  suffers  much  and  is  unrelieved  by 
medical  treatment,  or  if  in  consequence  of  his  occupation 
or  other  cause  he  cannot  submit  to  a  long  course  of  medical 
and  dietetic  treatment,  operation  is  justified.  This  is 
particularly  the  case  when  the  patient  understands  the 
risks  and  is  still  anxious  for  operation. 

Motor  inefficiency  of  the  second  degree  is  an  absolute 
indication  for  operative  treatment  ;  this  is  also  the  case 
when  the  symptoms  steadily  advance  in  spite  of  medical 
treatment,  the  urine  becoming  small  in  quantity  and  the 
patient  losing  weight  and  strength. 

The  primary  object  of  operation  will  be  to  deal  with  the 


DISEASES    OF    THE    STOMACH.  195 

actual  cause  of  the  stenosis,  that  is  to  say,  in  cancer  by 
resection,  in  the  case  of  adhesions  by  their  detachment. 
In  cicatricial  stenosis,  however,  and  in  inoperable  cancer, 
gastro-enterostomy  is  the  method  of  choice  for  the  relief  of 
obstruction.  Hour-glass  stomach  may  be  dealt  with  either 
by  gastrogastrostomy,  gastro-enterostomy,  or  gastroplasty, 
or  a  combination  of  more  than  one  method. 

Contra-indications. — All  the  conditions  which  militate 
against  the  success  of  a  serious  operation — advanced  age, 
marked  atheroma,  heart  lesions,  diabetes,  etc. — are  contra- 
indications. 

If  the  clinical  phenomena  point  to  a  motor  inefficiency 
of  a  slight  degree,  operation  should  not  be  advised  until 
medical  treatment  has  been  given  a  trial.  In  the  presence 
of  tetany  or  symptoms  of  auto-intoxication,  such  as 
acetonuria,  albuminuria.  Trousseau's  sign,  etc.,  operation 
is  not  advisable. 

Gastric  neuroses  are  in  general  not  suitable  for  operative 
treatment. 

Prognosis. — Results  of  operation.  The  results  of  opera- 
tion vary  with  the  nature  of  the  causative  lesion.  In 
many  cases  recovery  is  complete,  the  pains  and  stagna- 
tion phenomena  entirely  disappear,  and  the  motor  and 
chemical  functions  return  to  the  normal.  In  carcinoma, 
however,  even  after  resection  the  gastric  secretion  does 
not  entirely  regain  its  normal  composition.  In  a  few  cases 
a  certain  degree  of  dyspepsia  and  motor  inefficiency  persist. 
In  many  cases  of  hour-glass  stomach  the  result  of  operation 
has  been  very  good  ;  Moynihan  has  reported  six  recoveries, 
Frada  three.  The  operative  mortality  of  the  condition  is 
8"9  per  cent. 

Risks  of  operation. — The  risks  of  operation,  apart  from 
those  common  to  abdominal  section,  depend  upon  the 
extent  of  the  necessary  procedure.  Gastric  resection, 
whether  for  simple  or  malignant  stenosis,  is  attended  by 
the  highest  mortality,  while  that  associated  with  gastro- 
enterostomy and  pyloroplasty  is  much  smaller  (See  articles 
on  (iastric  Ulcer  and  Carcinoma  of  the  Stomach). 

Pneumonia  occurs  in  a  certain  proportion  of  cases,  and 
is  often  of  a  severe  type.  After  gastro-enterostomy,  peptic 
ulcer  of  the  jejunum  has  been  recorded,  and  in  a  few  cases 
has  led  to  fatal  perforation. 


196  IXDICATIONS    FOR    OPERATION    IN 

Without  operation. — Gastric  inefficiency  of  the  first 
degree  is  often  successfully  treated  by  medicinal  and 
dietetic  means.  In  marked  inefficiency,  on  the  other  hand, 
the  patient  steadily  loses  ground  and  eventually  succumbs. 
In  a  fair  number  of  cases  generalized  tetany  is  the  cause  of 
death  ;  in  three  under  my  own  observation  the  convulsions 
involved  the  extremities  and  back,  and  finally  the  diaphragm 
and  the  laryngeal  muscles.  In  hour-glass  stomach  the 
prognosis  is  similar  :  the  patient  suffers  from  inanition  and 
exhausting  pain,  and  the  affection  may  end  in  perforation 
or  fatal  exhaustion. 

LITERATURE. 

Mikulicz  und  Kausch.  Pylorusstenose.  Handbuch  der  prakt. 
Chir      Bd.  iii.     v.  [Mikulicz,  Bergmann  u.  Bruns.      1903. 

EwALD.  Diagnostik  des  Sanduhrmagens.  Deutsche  Arch.  f. 
klin.  Med.     Bd.'lxxiii. 

Lindner  und  Kuttner.  Die  Chirurgie  des  Magens.  Berlin, 
1898. 

H.  Weiss.  Der  Sanduhrmagens.  Centralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chir.      1898. 

H.  Petersen.  L^eber  die  chirurgische  Behandlung  gutartiger 
Magenerkrankungen.    Deutsche  med.  Wochen, ,  1899,  Nos.  24  and  25. 

Hartmann  et  SouPAULT  Les  Resultats  Eloignes  de  la  Gastro- 
enterostomie.     Rev.  de  Chir.,  1899,  pp.  137. 

Mathieu.     Maladies  de  rEstomac.      Paris,   1901. 

Fleiner.    Krankheiten  des  Verdauungstraktes.    Stuttgart.    1896. 

Kausch.  Ueber  funktionelle  Ergebnisse  nach  Operationen  am 
Magen.     Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  iv. 

Kronlein.  LTeber  Ulcus  und  Stenose  des  Magens  nach  Trauma. 
Ibidem. 

Maragliano.  Erfahrungen  a.  d.  Gebiete  der  Magen-Darm- 
chirurgie.     Beitr.  z.  klin.  Chir.,  Bd.  xli. 

Monprofit.  De  la  Gastro-Enterostomie  pour  Estomac  Bilocu- 
laire.     Arch.  Prov.  de  Chir.,  Feb.,  1904. 

Moynihan.  Hour-glass  Stomach.  Brit  Med.  Jour.,  Feb. 
20,  1904. 

Frada.  La  Gastro-enterostomia  nello  Stomaco  a  Clessidra. 
Riforma  Medica.     1901. 


CONGENITAL    HYPERTROPHIC    STENOSIS   OF    THE 
PYLORUS. 

This  condition  is  usually  found  in  children  of  healthy 
parents,  but  more  than  one  infant  in  the  same  family  may 
be  affected. 


DISEASES    OF    THE    STOMACH.  197 

Pathological  Anatomy. — Usually  the  pyloric  stenosis 
is  of  a  most  marked  degree ;  the  wall  is  much  thickened, 
due  to  the  hypertrophy  of  the  muscular  coat.  The  stomach 
is  usually  dilated. 

Clinical  Course. — The  most  important  signs  are 
uncontrollable  vomiting,  setting  in  soon  after  birth,  and 
the  presence  of  a  lump  in  the  epigastrium.  Cachexia 
usually  supervenes  in  a  short  time.  There  is  often  both 
motor  and  chemical  inefficiency  of  the  stomach  and 
obstinate  constipation.  If  constant  vomiting  comes  on 
soon  after  birth,  and  the  vomited  matter  never  contains 
bile  pigment,  while  at  the  same  time  there  is  a  lump  in  the 
epigastrium  and  exaggerated  peristalsis,  the  diagnosis  is 
clear. 

INDICATIONS  FOR  OPERATION. 

If  the  characteristic  symptoms  are  present,  and  do  not 
yield  to  internal  treatment,  and  if  the  child  is  losing  weight, 
operation  is  called  for.  It  is  urgent  when  the  child,  although 
hungry,  can  no  longer  take  the  breast.  The  usual  and  only 
satisfactory  procedure  is  gastro-enterostomy.  Operation 
should  not  as  a  rule  be  advised  until  a  trial  has  been  given 
to  medical  treatment. 

Prognosis. — Trautenroth  has  collected  12  cases  sub- 
mitted to  operation  ;  among  these  there  were  5  fatalities  ; 
the  remaining  7  made  a  complete  recovery.  Without 
operation  the  majority  of  cases  succumb  to  inanition  ;  in 
some  cases  the  symptoms  are  relieved  by  medical  treatment. 

LITERATURE. 

Neurath.  Die  angeborene  Pylorusstenose  der  Sauglinge. 
Centralb.  f.  d.  Gren^gebiete  d.  Med.  u.  Chir.      1899. 

Trautenroth.  Ueber  die  Pylorusstenose  der  Sauglinge.  Mitteil. 
a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ix. 

ScHOTTEN.  Die  angeborene  Pylorusstenose  der  Sauglinge. 
Volkmann's  Hefte.     New  Series,  No.  368,  1904. 

MacCaw  and  Campbell.  Congenital  Hypertrophic  Stenosis 
of  the  Pylorus.    Brit.  Med.  Jour.,  June  25,  1904. 

Weill  et  Pehu.  Les  Stenoses  Pyloriques  chez  le  Nouveau-ne 
et  le  Nourisson.  Gaz.  des  Hopit.,  Nos.  1 1 2  and  115,  1901. 


CHAPTER    XIV. 

Diseases    of    the    Intestines. 


Chapter  XIV. 
DISEASES    OF    THE    INTESTINES. 

DUODENAL    ULCER. 

The  round  ulcer  of  the  duodenum  is  a  distinct  clinical 
type,  and  it  is  therefore  proper  that  it  should  be  given  a 
special  article.  It  is  more  common  in  men  than  in  women, 
and  occurs  most  frequently  in  individuals  of  middle  age  and 
in  young  children.  Alcoholism,  chronic  tobacco  poisoning, 
burns,  and  frost-bites  appear  to  have  etiological  relationship 
with  the  condition.  It  has  been  found  in  a  considerable 
number  of  instances  in  patients  affected  with  nephritis  and 
cardiac  disease.  There  is  a  difference  of  opinion  as  to 
whether  it  ever  results  from  trauma. 

Pathological  Anatomy. — The  ulcer  is  usually  solitary, 
varying  in  size  from  a  lentil  to  a  florin.  It  is  usually  found 
in  the  upper  horizontal  portion  of  the  duodenum.  Perfora- 
tion occurs  in  a  large  proportion  of  cases,  probably  more 
than  a  third,  either  into  the  general  peritoneal  cavity  or 
some  neighbouring  organ.  Subphrenic  abscess  is  relatively 
common.  When  the  ulcer  heals,  the  resulting  cicatricial 
contraction  may  cause  stenosis  ;  profuse  haemorrhage 
sometimes  occurs  from  erosion  of  large  vessels. 

Clinical  Course. — In  many  cases  there  are  either  no 
symptoms,  or  only  some  slight  complaint  of  discomfort.  In 
other  cases  there  is  pain  coming  on  usually  a  long  time 
after  a  meal,  and  often  relieved  by  again  taking  food  or  by 
alkalies.  There  is  tenderness  as  well  as  pain  in  the  neigh- 
bourhood of  the  pylorus.  Vomiting  and  retention  of 
stomach  contents  are  common,  and  in  a  third  of  the  cases 
there  is  haemorrhage,  evidenced  by  melsena  or  hccmatemesis. 

Chronic  perforation  of  the  ulcer  usually  causes  intense 
localized  pain  and  peritoneal  symptoms,  i.e.,  meteorism, 
diffuse   tenderness,   fever,    and   sometimes   free   exudation. 


202  INDICATIONS    FOR    OPERATION    IN 

If  signs  of  subphrenic  abscess  develop,  the  gastric  symptoms 
are  overshadowed.  In  other  cases  pus  maizes  its  way  down- 
wards, and  appendicitis  is  simulated. 

Acute  perforation  is  associated  with  symptoms  similar  to 
those  of  perforation  of  a  gastric  ulcer. 

Diagnosis. — When  there  is  a  history  of  long-continued 
pain  in  the  right  hypochondrium,  which  reaches  its 
maximum  some  hours  after  taking  food,  is  not  particularly 
altered  by  vomiting,  and  is  increased  by  pressure  in  the 
pyloric  region,  duodenal  ulcer  will  be  suspected,  and  the 
diagnosis  will  be  sustained  if  blood  is  present  in  the  stools. 
It  will  be  remembered  that  the  condition  runs  a  chronic 
course,  and  is  particularly  associated  with  extensive  burns. 
It  is  only  rarely  that  a  definite  diagnosis  is  made. 

With  regard  to  the  differentiation  from  gastric  ulcer,  it 
should  be  remembered  that  duodenal  ulcer  is  particularly 
common  in  the  male,  and  that  it  is  not  often  accompanied 
by  haematemesis.  Cholelithiasis  is  very  rarely  associated 
with  mel?ena,  and  the  history  of  the  case,  the  examination 
of  the  gall-bladder  by  palpation,  and,  possibly,  the  passage 
of  calculi,  will  render  the  diagnosis  clear. 

From  appendicitis  duodenal  ulcer  is  distinguished  by  the 
seat  of  the  pain,  the  maximum  point  of  tenderness,  and  the 
periodicity  of  the  pain  ;  a  tender  swelling  in  the  right  iliac 
region  will  of  course  point  to  the  appendix. 

INDICATIONS   FOR  OPERATION. 

Duodenal  ulcer  has  rarely  been  directly  treated  by 
operation  on  account  of  the  difficulties  of  diagnosis.  The 
indications  for  operation  are  virtually  the  same  as  in  gastric 
ulcer  (q.v.).  It  is  usually  confounded  with  the  latter,  and 
the  actual  seat  of  the  ulcer  has  often  been  demonstrated 
only  at  operation  or  autopsy. 

Perforation  occurs  in  a  large  proportion  of  cases,  and 
furnishes  an  absolute  indication  for  operation.  The  same 
is  true  of  the  other  common  complication,  subphrenic 
abscess.  As  the  subphrenic  abscess  following  duodenal 
ulcer  does  not  differ  in  features  from  that  arising 
from  other  causes,  the  reader  is  referred  to  the  special' 
article  on  the  subject.  It  may  simply  be  said  here 
that  the  definite  presence  of  a  subphrenic  empyema  calls 
for   operation,    wliatever   the   cause.     Chronic    perforation 


DISEASES    OF    THE    INTESTINES.  203 

may  give  rise  to  abscess  in  other  situations,  and  these 
also  necessitate  operation. 

Repeated  hcemorrhages,  revealed  by  melaena  or  ha^mate- 
mesis,  constitute  an  indication  for  operation  if  medical 
treatment  fails  and  the  patient  becomes  an?emic  and  declines 
in  general  health.  Gastro-enterostomy  is  the  operation  of 
choice. 

Contra-indications. — Operation  will  not  be  advised  until 
medical  treatment  has  been  properly  tried.  A  single 
haemorrhage,  even  if  large  in  amount,  does  not  necessitate 
operation.  Generally  speaking,  the  contra-indications  are 
the  same  as  in  gastric  ulcer. 

Prognosis. — Results  of  operation. — In  cases  of  acute 
perforation  the  prognosis  is  very  serious,  even  if  operation 
is  done  soon  after  the  accident.  Laspeyres  has  collected 
17  cases  ;  in  2  the  perforation  could  not  be  closed,  and  had 
to  be  tamponed  ;  both  were  fatal.  Of  the  remainder  a 
third  recovered.  In  two  unpublished  cases  of  my  own, 
death  occurred  in  spite  of  operation.  In  Pagenstecher's  28 
collected  cases  the  mortality  was  86  per  cent.  The  figures 
of  Weisl  and  Foote  show  how  important  is  early  operation  ; 
those  operated  on  within  eleven  hours  gave  a  mortality  of 
39  per  cent,  those  operated  on  between  the  twelfth  and 
twenty-fourth  hour  gave  a  mortality  of  76  per  cent,  and  of 
those  dealt  with  later,  87  per  cent  died. 

In  a  considerable  number  of  cases  complete  recovery  has 
followed  gastro-enterostomy. 

These  figures  show  that  duodenal  ulcer  is  a  grave  disorder, 
and  often  causes  complications  which  have  to  be  dealt  with 
by  operation  to  save  life.  The  mortality  of  these  complica- 
tions is  still  to-day  very  high. 

Without  operation. — Death  occurs  in  many  cases  from 
perforation  or  profuse  haemorrhage.  In  some  cases  the 
affection  runs  a  very  chronic  course ;  remissions  alternate 
witli  exacerbations  over  a  period  of  many  years.  In  a 
not  inconsiderable  number  of  cases  healing  results  in  a 
cicatrization  which  causes  stenosis. 

LITERATURE. 

E.JiSi'iCYKrcs.  Das  runde  Duodenalgeschwiir.  Ccntralb.  f.  d. 
<ircnzgebictc  d.  Med.  u.  Chir.,  igo2. 

XoTHNAG7-:(,.  Krankheiten  dcs  Darmes  und  des  Peritoncurns. 
2nd  Ed.,  1003. 


204  INDICATIONS    FOR    OPERATION    IN 

BuRWiNKEL.  Peptisches  Duodenalgeschwiir.  Deut.  med.  Wochen. 
No.  52,  1898. 

Pagenstecher.  Die  chirurgische  Behandlung  des  Duodenal- 
geschwiires.     Deutsche.  Zeit.  f.  Chir.,  Bd.  lii. 

Darras.  De  la  Perforation  dans  I'Ulcere  Simple  du  Duodenum. 
These  de  Paris,    1897. 

Schwarz.  Peritonites  Septiques  Diffuses  Produits  par  1' Ulcer 
Perforant  du  Duodenum.  Bullet,  et  Mem.  de  la  Soc.  d;  Chir. 
Paris,  1898. 

Savariand.  Les  Gastrorrhagies  dans  I'Ulcere  du  Duodenum  et 
leur  Traitement  Chirurgical.       Gaz.  des  Hopit.,  Jan.,    1899. 

Perry  and  Shaw.  On  Diseases  of  the  Duodenum.  Guy's 
Hospital  Reports,  p.   171,   1894. 

Ladeveze.  Traitement  de  I'Ulcere  du  Duodenum.  These  de 
Paris,   1 900. 

Lennander.  Die  Behandlung  des  perforirenden  Magen-  und 
Duodenalgeschwiires.  INlitteil  a.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
Bd.  iv. 


DUODENAL    STENOSIS. 

Etiology  and  Pathological  Anatomy. — The  cause  of 
duodenal  stenosis  may  be  outside  the  bowel,  as  in  the  case 
of  adhesions,  tumours  of  the  pancreas,  and  glandular 
tumours,  or  within  the  lumen  itself,  as  in  cicatricial  con- 
traction after  ulcer,  gall-stones,  and  tumours  of  the  gut. 
The  point  of  stenosis  may  be  in  any  of  the  three  parts 
of  the  duodenum. 

Clinical  Course. — Obstruction  may  set  in  acutely, 
and  begin,  as  in  other  forms  of  acute  obstruction,  with 
marked  collapse,  vomiting,  etc.  Meteorism  and  fcecal 
vomiting,  however,  are  absent,  and  fgeces  and  flatus  may  be 
passed.     The  stomach  is  often  much  distended. 

Suprapapillary  stenosis  is  clinically  similar  to  pyloric 
stenosis,  and  cannot  be  distinguished  from  it.  When  the 
obstruction  is  in  the  neighbourhood  of  the  papilla,  the  signs 
of  common  duct  obstruction  are  present  (jaundice,  bile  in 
the  urine,  and  colourless  stools),  and  the  stools  are  fatty, 
from  obstruction  of  the  duct  of  Wirsung.  When  the 
stenosis  is  below  the  papilla  there  is  often  copious  vomiting 
of  bilious  matter,  and  on  washing  out  the  stomach  the  fluid 
at  the  end  of  the  washing  is  bile-stained.  This  last  sign  was 
most  marked  in  one  of  my  cases.  The  gastric  secretion 
often  shows  no  diminished  digestive  capacity,  but  free 
hydrochloric    acid    is    often     absent.       This     phenomenon 


DISEASES    OF    THE    INTESTINES.  205 

is  sometimes  only  transitory,  and  the  variability  of  the 
symptoms  is  quite  a  characteristic  feature  of  infrapapillary 
stenosis.  When  the  stomach  is  empty  of  food,  alkaline 
duodenal  secretion  can  sometimes  be  obtained  from  it, 
showing  action  on  proteid,  starch,  and  fat. 

Diagnosis. — The  symptoms  just  enumerated  will  be 
sui^cient  for  a  diagnosis.  The  vomited  matter  is  abundant 
and  the  epigastrium  distended.  General  meteorism  is 
against  duodenal  stenosis.  Differentiation  from  pyloric 
stenosis  is  often  not  easy ;  the  chemical  changes,  however,  in 
many  cases  demonstrate  the  situation  of  the  stenosis. 
Chronic  obstruction  of  the  common  duct  by  calculus  is 
distinguished  from  duodenal  obstruction  by  the  absence  of 
duodenal  secretion  from  the  stomach  and  by  the  histor}^  of 
the  case. 

INDICATIONS  FOR  OPERATION. 

Operative  treatment  is  necessary  whenever  serious 
symptoms  make  their  appearance,  and  do  not  yield  to 
internal  treatment.  Under  this  heading  come  persistent 
vomiting,  increasing  inanition,  diminution  of  urine  secretion. 
The  presence  of  these  justifies  intervention. 

The  operation  will  either  be  gastro-enterostomy,  removal 
of  a  biliary  calculus,  or  the  separation  of  adhesions.  The 
removal  of  a  neoplasm  will  depend  upon  the  presence  or 
absence  of  metastases. 

Sometimes  duodenal  perforation  is  a  consequence  of 
stenosis,  and  operation  will  of  course  be  done  here  as  in  a 
perforating  ulcer,  in  both  the  acute  and  the  chronic  types. 

Contra-indication. — Operation  will  not  be  advised  until 
lavage  and  medical  treatment  have  been  tried  and  failed  to 
relieve. 

Prognosis. — Operation  has  been  relatively  seldom  done 
for  duodenal  stenosis.  The  risks  are  the  same  as  in  the 
operation  for  duodenal  ulcer.  In  many  of  the  cases  the 
condition  has  been  entirely  cured.  If  no  operation  is 
undertaken  the  symptoms  can  sometimes  be  relieved  in 
jjart  by  medical  treatment ;  if  this  is  not  the  case,  death 
will  follow  sooner  or  later  from  inanition  and  cachexia. 

LITERATURE. 

Albu.  Die  Diagnose  und  Therapie  der  Duodenalstenose. 
Ccntralb,  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,   1899. 


2o6  INDICATIONS    FOR    OPERATION    IN 

XoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneuras. 
2nd  Ed.      1903. 

Adrien  Pic.  Cancer  du  Duodenum.  Rev.  de  Med..  1894  and 
1895. 

Laspevres.  Das  Runde  Duodenalgeschwiir.  Centralb.  f.  d. 
Grenzgebiete  d.  ;\Ied.  u.  Chir.,   1902. 

Jaboulay.  Ulcere  du  Duodenum.  Duodenoplastie.  Lyon. 
Med.,   No.  27,    1899. 

Perry  and  Shaw.  Diseases  of  the  Duodenum.  Guy's  Hospital 
Reports.   1894. 

CoDiviLLA.     Contributo  alia  Chirurgia  Gastrica.     Bologna.    1898. 

Wilms.  Die  Stenose  des  unteren  Duodenum.  Beitr.  z. 
klin.  Chir.     Bd.  xviii. 


INTESTINAL  TUBERCULOSIS. 

Etiology. — In  the  great  majority  of  cases  intestinal 
tuberculosis  is  a  secondary  affection,  and  is  therefore 
dependent  on  all  conditions  which  tend  to  establish  tuber- 
culosis in  the  lungs  and  other  organs.  It  may  develop  at 
any  age  ;  the  tumour-like  tuberculous  masses  are  most 
frequently  found  in  the  middle-aged. 

Pathological  Anatomy. — There  are  three  types  dis- 
tinguished : — (i)  The  disseminated  type,  without  tendency 
to  healing  ;  (2)  The  solitary  or  multiple  type,  with  tendency 
to  healing  ;  (3)  The  tumour-like  tuberculosis  of  the  ileo- 
Cctcal  region.  In  the  second  type,  solitary  or  multiple  ulcers 
are  formed,  and  the  solitary  ulcer  is  usually  in  the  ileoccecal 
region.  If  the  ulceration  extends  transversely  to  the  axis 
of  the  bowel,  stenosis  tends  to  follow  its  cicatrization.  Such 
strictures  are  not  uncommonly  multiple  ;  as  many  as  fifteen 
have  been  met  with  ;  sometimes  they  are  ^annular,  some- 
times tubular.     They  are  most  frequent  in  the  ileum. 

The  tumour-like  mass  of  the  ileocaecal  region  remains 
long  localized,  and  stenosis  may  result  from  great  thickening 
of  the  bowel  wall. 

According  to  Conrath,  the  lesions  of  intestinal  tuberculosis 
may  commence  in  the  subserous  layer  or  as  ulcers  of  the 
mucous  membrane.  In  some  cases  they  are  more  numerous 
in  the  ileum,  in  others  in  the  csecum,  and  in  old-standing 
cases  they  may  be  widely  distributed. 

The  peritoneum  may  remain  free  from  involvement,  even 
in  cases  where  the  other  lesions  have  long  been  present. 

Clinical  Course. — With  stenosing  tuberculosis  of  the 


DISEASES    OF    THE    INTESTINES.  207 

bowel,  patients  are  usually  in  indifferent  general  health,  and 
usually  have  clinically  recognizable  tubercular  lesions  in 
other  organs.  The  disease  as  a  rule  begins  insidiously,  and 
the  first  sign  is  irregularity  of  the  bowels,  and  constipation, 
alternating  sometimes  with  diarrhoea.  There  is  usually  a 
complaint  of  dull  intermittent  pains  in  the  abdomen,  the 
attacks  becoming  more  and  more  frequent.  During  an 
attack  there  is  exaggerated  peristalsis,  and  distended  and 
firmly-contracted  coils  are  to  be  felt  ;  the  pains  are  severe, 
and  pass  off  with  borborygmi.  The  peristaltic  movements 
concern  the  small  intestine.  Vomiting  is  common,  and 
during  the  attack  neither  faeces  nor  flatus  are  passed. 
Occasionally  there  is  slight  fever. 

The  symptoms  of  the  tumour-like  ileocecal  tuberculosis 
are  also  those  of  intestinal  stenosis,  but  the  typical  attacks 
of  stenosis  may  be  preceded  for  months  and  even  years  by 
indefinite  pains  in  the  abdomen  without  any  constant 
localization. 

Attacks  of  severe  diarrhoea  or  of  large  hgemorrhages  are 
unusual.  After  the  symptoms  have  been  present  for  some 
time,  a  hard,  nodular,  slightly  tender  and  mobile  mass 
becomes  recognizable  in  the  ileocsecal  region,  which  grad- 
ually becomes  immobile.  In  some  cases  cold  abscesses  are 
formed,  and  perforation  of  the  tuberculous  bowel  may  take 
place  into  other  hollow  organs  or  the  exterior. 

In  both  of  these  types  of  intestinal  tuberculosis  the 
peritoneum  is,  as  a  rule,  not  affected. 

Diagnosis. — If  intestinal  stenosis  makes  its  appearance 
in  a  young  individual,  with  tuberculosis  in  some  other  organ, 
it  is  probably  tuberculous  in  nature.  The  discovery  of 
small  and  repeated  haemorrhages  in  the  stools  revealed  by 
the  guaiac  or  aloin  tests,  or  of  tubercle  bacilli,  will  make  the 
diagnosis  certain.  If  it  is  possible  to  diagnose  multiple  in- 
testinal stenosis  in  a  young  patient  without  syphilitic  lesions 
or  history,  the  probability  is  that  it  is  due  to  tuberculosis. 

In  several  cases  I  have  found  it  possible  to  diagnose 
multiple  tubercular  stricture  without  palpable  tubercular 
masses.  In  all  I  have  met  with  five  such  cases,  and  I  look 
upon  the  following  points  as  characteristic  :  the  repeated 
observation  of  simultaneous  spasmodic  contraction  in 
different  segments  of  bowel  at  a  distance  from  one  another, 
the  intervening  segments  remaining  fiaccid,  particularly  if 


2o8  INDICATIONS    FOR    OPERATION     IN 

these  are  of  different  diameter  and  there  is  no  general 
meteorism  ;  the  practically  identical  position  of  these 
contracted  segments  during  the  different  attacks  ;  the 
simultaneous  disappearance  of  the  contractions,  along  with 
marked  intestinal  gurgling. 

One  of  my  patients  was  a  man  of  twenty-three,  who 
complained  of  cough  and  presented  an  early  consolidation 
of  the  right  apex.  For  three  years  he  had  had  attacks  of 
abdominal  pain  off  and  on,  the  attacks  passing  off  with 
gurgling,  and  increasing  in  frequency.  Contractions,  some- 
times simultaneous,  of  three  different  thickened  intestinal 
coils,  could  be  recognized,  and  the  diagnosis  of  multiple 
tubercular  stricture  of  the  bowel  was  made.  The  operation 
revealed  three  tubercular  strictures,  the  lowest  in  the  ileo- 
caecal  region.  Entero-anastomosis  was  performed.  The 
patient  died  from  peritonitis  on  the  lifth  day  ;  the  autopsy 
showed  the  presence  of  a  fourth  stricture. 

In  another  case  multiple  tubercular  stenoses  were  diagnosed 
from  the  presence  of  similar  symptoms  ;  there  was  no 
syphilis  and  no  pulmonary  tuberculosis.  Operation  revealed 
the  presence  of  twelve  tubercular  strictures.  Entero- 
anastomosis  was  performed,  and  two  metres  of  small  intestine 
were  excluded.  The  symptoms  of  stenosis  disappeared,  and 
except  for  insignificant  pains  the  boy  is  well  a  year  and  a 
half  after  operation. 

Ileocaecal  tuberculosis  in  the  form  of  a  tumour-like  mass 
can  be  recognized  when  intestinal  stenosis  is  associated  with 
a  mass  in  the  right  iliac  region  in  a  tuberculous  individual, 
the  symptoms  being  chronic  and  associated  with  a  sub- 
febrile  temperature. 

A  case  under  my  care  was  that  of  a  woman  aged  50,  with 
earh^  apical  lesions.  Associated  with  diarrhoea  and  severe 
pain,  a  hard  nodular  mass  developed  in  the  ileocaecal  region. 
The  general  health  suffered  greatly,  and  she  became  anaemic. 
The  pulmonary  condition,  which  was  confirmed  by  bacterio- 
logical examination,  led  one  to  diagnose  intestinal  tuber- 
culosis. The  operation  showed  marked  thickening  of  the 
wall  of  the  lower  part  of  the  ileum  and  of  the  caecum,  and 
tubercular  ulcers  of  the  mucous  membrane  in  the  same 
portions  of  gut.  The  lumen  of  the  bowel  was  reduced  to 
the  diameter  of  a  quill.  Resection  was  performed,  and  the 
intestinal  symptoms  disappeared. 


DISEASES    OF    THE    INTESTINES.  209 

Differential  diagnosis  is  often  difficult  and  sometimes 
impossible.  From  new  growth  the  affection  is  distinguished 
by  its  more  chronic  course,  by  the  association  with  tuber- 
cular lesions  elsewhere,  and  by  preceding  diarrhoea.  These 
points  led  me  to  diagnose  tuberculosis  in  a  patient  in  spite 
of  his  advanced  age,  whom  I  saw  some  years  ago,  and  the 
operation  proved  that  the  opinion  was  correct.  Long 
observation  is  sometimes  necessary  before  cholelithiasis  or 
nephrolithiasis  can  be  excluded. 

One  of  my  cases  was  that  of  a  hospital  sister,  apparently 
in  good  health.  For  some  years  she  had  suffered  from 
severe  pains,  which  were  first  ascribed  to  cholelithiasis  and 
later  to  renal  calculus.  I  saw  her  during  an  attack,  found 
a  lump  in  the  ileocsecal  region,  and  diagnosed  chronic 
appendicitis  ;  the  possibility  of  tuberculosis  was  also  con- 
sidered in  view  of  her  occupation.  A  tumour-like  mass  was 
found  at  the  operation,  involving  the  caecum  and  causing 
stenosis.  Entero-anastomosis  was  performed,  and  per- 
manent relief  of  symptoms  followed. 

Before  operation  diagnosis  may  be  impossible  from  chronic 
non-tubercular  appendicitis,  chronic  intussusception,  and 
other  conditions. 

INDICATIONS   FOR  OPERATION. 

Many  of  these  cases  are  operated  on  for  some  other 
supposed  condition,  the  diagnosis  being  made  only  when 
the  abdomen  is  opened.  There  are  two  signs  which  indicate 
the  necessity  for  intervention  :  symptoms  of  intestinal 
stenosis,  and  the  presence  of  a  mass  in  the  ileocsecal  region. 

If  the  symptoms  of  intestinal  stricture  are  definite,  and 
if  in  addition  to  the  sign  of  contracture  the  bowel  wall  can 
be  felt  to  be  markedly  hypertrophied,  the  stenosis  is 
evidently  extreme,  and  surgical  intervention  is  absolutely 
necessary. 

The  presence  of  a  mass  in  the  ileocaecal  region,  associated 
with  pain,  fever,  or  stenosis  symptoms,  is  also  an  indication 
for  operation. 

If  the  signs  are  sufficient  for  a  diagnosis  of  multiple 
stricture,  this  in  itself  is  an  indication  for  operation. 

The  operative  procedures  employed  are  :  exclusion  of  a 
portion  of  the  gut  by  entero-anastomosis,  or  resection  of 
tlio  affected  segment,  a  much  more  serious  undertaking. 

14 


2IO  INDICATIONS    FOR    OPERATION    IN 

Contra-indications. — A  state  of  pronounced  cachexia, 
advanced  pulmonary  tuberculosis,  amyloid  disease,  and 
any  serious  complications  in  other  organs,  contra-indicate 
operation.  If  tubercular  peritonitis  is  present,  no  com- 
plicated operative  procedure  is  advisable. 

Prognosis. — Results  of  operation. — Eighty-one  cases  of 
tubercular  ileocsecal  "  tumour  "  have  been  analysed  by 
Conrath.  In  48  cases  resection  with  anastomosis  was 
practised,  and  of  these  9  either  died  after  the  operation  or 
remained  unhealed,  while  in  5  others  it  was  necessary  to 
establish  an  artificial  anus.  With  regard  to  the  end  results, 
30  cases  who  recovered  after  operation  had  the  following 
subsequent  histories  :  11  died  from  a  month  to  four  years 
later,  4  from  local  return  or  tubercular  peritonitis,  the 
remainder  from  phthisis  pulmonalis  ;  of  the  19  survivors, 
2  had  had  recurrence,  and  16  remained  well  several  years 
after  operation. 

Entero-anastomosis  was  performed  in  10  of  Conrath's 
cases,  with  9  recoveries,  and  in  8  of  these  the  relief  was 
permanent  ;  in  8  cases  the  affected  segment  was  excluded, 
some  with  and  others  without  subsequent  removal  of  the 
excluded  portion ;  two  of  these  cases  died  from  the  operation. 

There  are  many  unpublished  cases.  Lotheissen,  for 
example,  has  performed  entero-anastomosis  in  five  of  my 
cases  during  the  last  two  years. 

After  operation  the  intestinal  troubles  have  in  many  cases 
disappeared,  and  the  general  health  has  become  excellent. 
In  other  cases,  in  some  of  my  own  for  example,  attacks  of 
pain  and  distension  have  persisted  during  the  first  month 
after  operation,  relieved  by  aperients.  Probably  these  were 
due  to  spasmodic  contractions  of  the  bowel.  Several  of 
these  cases  have  later  entirely  lost  their  symptoms. 
Occasionally,  in  spite  of  operation,  the  tubercular  pro- 
cess progresses  and  gives  rise  to  abscess  or  tubercular 
peritonitis. 

Without  operation. — The  stenosis  is  progressive  in 
character,  and  the  pains  and  other  symptoms  increase  in 
severity.  Acute  obstruction  or  perforation  of  the  bowel 
may  prove  rapidly  fatal.  If  a  perforation  occurs  gradually, 
intestinal  fistulas  or  artificial  anus  may  result.  In  some 
cases  a  slowly  progressive  suppurative  peritonitis  develops  ; 
this  I  have  myself  seen  in  several  cases. 


DISEASES    OF    THE    INTESTINES.  211 

LITERATURE. 

CoNRATH  Die  lokale  chronische  Caecumtuberkulose.  Beitr.  z. 
klin.  Chir.,  Bd.  xxi. 

Reach.  Die  multiplen  Darmstenose.  Centralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chir.      1900. 

HoFMEiSTER.  Uebcr  multiple  Darmstenosen  tuberculosen 
Ursprungs.     Beitr.  z.  klin.  Chir.,  Bd.  xvii. 

H.  ScHLESiNGER.  Zur  Diagnose  multipler  Darmstenosen. 
Centralb.  f.  innere  Med.      1903. 

NoTHNAGEL.  Krankheitcn  des  Darmes  und  des  Peritoneums. 
2nd  Ed.      1903. 

Alglave.  Traitement  Chirurg.  de  la  Tuberculose  du  Segment 
Ileocaecal  de  ITntestin.     These  de  Paris-.      1904. 

Belgrand.  Tuberculose  Chirurgicale  de  la  Region  IleocaecaL 
These  de  Paris.      1904. 

Delore  et  Patel.     Rev.  de  Chir.  pp.  305,  669,  and  797.      1901. 

Berard  et  Leriche.  Les  Stenoses  Tuberculeuses  Multiples  de 
ITntestin  Grele  cliez  ITnfant.     Rev.  de  Chir.      1904,  Ncs.  8  and  9. 


ACTINOMYCOSIS    OF    THE    INTESTINE. 

Infection  usually  comes  from  eating  wheat  grains,  and 
most  commonly  occurs  in  men  of  middle  age. 

Pathological  Anatomy. — The  rectum  and  the  cascum 
are  the  parts  most  often  affected.  Of  iii  cases  collected 
by  Grill,  in  62  the  caecum  and  appendix  were  the  certain  or 
probable  original  seat.  The  disease  is  a  chronic  inflam- 
matory process,  leading  at  one  and  the  same  time  to  tissue 
proliferation  and  tissue  necrosis,  extending  deep  to  the 
surface  and  invading  neighbouring  structures  after  the 
formation  of  adhesions.  In  some  cases  extension  is  chiefly 
towards  the  peritoneal  cavity,  in  others  towards  the 
abdominal  wall.  The  disease  often  causes  the  formation  of 
intestinal  fistulse  ;  the  infiltration  which  occurs  is  often 
very  wide  in  extent. 

Clinical  Course. — The  development  of  the  disease  is  of 
a  chronic  type.  The  following  stages  may  be  distinguished  : 
(i)  The  early  stage,  with  indefinite  phenomena  and  often 
intestinal  catarrh.  (2)  The  stage  of  tumour.  After  some 
months  a  mass,  which  often  reaches  considerable  proportions, 
forms,  usually  in  the  ileoccccal  region  ;  later  it  becomes 
incorporated  with  the  abdominal  wall,  is  ill-defined,  intensely 
hard,  and  usually  very  slightly  tender  to  pressure.  (3)  The 
stage    of    fistula;.     The    infiltration    usually    reaches    the 


212  INDICATIONS    FOR    OPERATION    IN 

surface  at  several  points,  and  forms  several  fistulfe,  with  a 
complicated  system  of  holes  and  passages.  The  character- 
istic yellow-gold  granules  are  found  in  the  pus.  The  fistulse 
may  connect  with  the  bowel,  and  the  discharge  is  then  fsecu- 
lent.  Symptoms  of  intestinal  stenosis  are  absent.  There 
is  usually  some  fever,  and  the  general  condition  suffers  to  a 
marked  degree.  Perforation  into  the  general  peritoneal 
cavity  is  very  unusual  ;  the  formation  of  fistulce  into 
neighbouring  organs  is  common. 

Diagnosis. — The  disease  is  sometimes  recognized  in  the 
second  stage,  when  there  is  an  infiltration  of  intense  hardness 
with  a  history  of  chronic  development  ;  more  often  the 
diagnosis  is  not  made  until  fistulfe  form,  the  granules  are 
recognized  in  the  pus,  or  the  organism  is  demonstrated  in 
portions  of  tissue  removed.  In  the  stage  of  freely  movable 
mass  in  the  ileocgecal  region,  a  delinite  diagnosis  from 
appendicitis,  carcinoma,  and  other  conditions  is  practically 
impossible.  When  invasion  of  the  abdominal  wall  has 
taken  place,  the  condition  is  distinguished  from  ordinary 
cellulitis  by  the  acute  course  of  the  latter  and  the  marked 
constitutional  disturbance,  and  from  true  tumours  of  the 
parietes  by  the  more  defined  limits  of  the  latter,  by  the 
absence  of  fever  and  of  extensive  infiltration  of  the  skin. 

When  fistulse  have  formed,  diagnosis  has  to  be  made  from 
tuberculosis,  chiefly  by  the  result  of  examination  of  the 
discharge,  and  from  syphilis. 

INDICATIONS    FOR    OPERATION. 

If  a  tumour  is  present  in  the  ileocaecal  region,  if  fever  and 
pain  are  present,  laparotomy,  with  resection  of  the  mass,  or 
entero-anastomosis,  is  indicated.  If  the  abdominal  wall  is 
infiltrated,  it  is  necessary,  if  iodide  of  potassium  gives  no 
result,  to  slit  up  the  whole  area  of  fistulous  tracts,  and  if 
this  proves  unsatisfactory  to  remove  the  whole  area  with 
the  knife  and  spoon. 

Contra-indications. — If  the  diagnosis  of  actinomycosis  is 
tolerably  certain  and  the  delimitation  of  the  mass  indefinite, 
it  is  not  of  much  use  attempting  radical  extirpation,  as  the 
disease  is  practically  certain  to  extend  in  spite  of  it. 

Prognosis. — Results  of  operation. — The  results  of  operative 
treatment  are  comparatively  good,  considering  that  it  is 
seldom  possible  to  remove  the  whole  area  of  disease.     Of 


DISEASES    OF    THE    INTESTINES.  213 

Grill's  III  cases  operated  on,  45  died,  22  were  cured,  and 
10  improved. 

Without  operation. — Without  eneirgetic  treatment  intestinal 
actinomycosis  is  a  very  aggressive  process,  and  never  tends 
to  spontaneous  cure.  Iodide  of  potassium  given  internally 
seems  to  have  some  favourable  influence  on  the  disease,  but 
recovery  without  operation  is  excessively  rare. 

LITERATURE. 

H.  Herz.  Ueber  Aktinomycose  des  Verdauungsapparates. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1900. 

O.  Frey.  Klinische  Beitr.  z.  Aktinomykose.  Beitr.  z.  klin. 
Chir.,  Bd.  xix. 

NoTHNAGEL.  Krankheiten  des  Darmes  und  des  Peritoneums, 
2nd  Ed.,   1903. 

Mikulicz  und  Kausch.  Krankheiten  des  Darmes.  Handbuch  d. 
prakt.  Chir.  Bergmann,  Mikulicz,  u.  Bruns.  Bd.  iii.  2nd  Ed. 
1903. 

Grill.  Aktinomykose  des  Magens  und  Darmes.  Beitr.  z.  kUn. 
Chir.,  Bd.  xiii. 

PoNCET.  De  rActinomycose  Ano-Rectale.  Gaz.  Hebdom.  de 
Med.  et  de  Chir.,  Sept.,  1898. 

Fairweather.  Actinomycosis  Commencing  in  the  Vermiform 
Appendix.     Brit.  Med.  Jour.,  June  27,  1897. 

Fantino  e  Grill.  Contribute  alio  Studio  dell'  Actinomicosi 
Umana.      Riforma  Medica.     Nos.   90-92    and    1 01-103,    1898. 


CHRONIC    DYSENTERY  AND   ULCERATIVE   COLITIS. 

Etiology  and  Pathological  Anatomy.  —Chronic  dysen- 
tery follows  the  acute  disease,  both  the  amoebic  form  and 
the  so-called  catarrhal  form.  The  ulcers  are  usually  in  the 
descending  colon,  are  often  of  considerable  depth  and  extent, 
and  have  thickened  edges.  When  extensive,  the  ulceration 
gives  a  dense,  thickened  feeling  to  the  whole  bowel.  Secon- 
dary peritonitis  is  uncommon. 

Under  the  title  of  ulcerative  colitis  a  series  of  affections 
is  described,  with  different  pathological  lesions  ;  catarrhal, 
dysenteric,  tubercular,  and  syphilitic  processes  have  been 
thus  grouped  together.  The  ulcerative  condition  may 
involve  more  or  less  the  whole  colon,  causing  dense  infiltra- 
tion throughout  its  whole  length. 

Clinical  Course. — Kartulis  describes  the  following 
clinical  types  of  chronic  dysentery  : — (i)  That  in  which  the 


214  INDICATIONS    FOR    OPERATION    IN 

symptoms  follow  an  acute  attack  and  persist  in  a  milder 
form  for  many  months.  (2)  In  the  course  of  convalescence 
from  acute  dysentery  a  relapse  takes  place,  and  improve- 
ment alternates  with  relapse  for  a  long  time.  (3)  At  the 
beginning  the  symptoms  are  only  those  of  catarrhal  diarrhoea, 
dysenteric  symptoms  coming  on  later. 

Tenesmus  is  not  pronounced  in  chronic  dysentery  ;  the 
stools  are  liquid,  of  greenish  or  black-brown  colour.  Blood, 
mucus,  and  pus  are  often  present  in  considerable  quantity. 
Pain  and  tenderness  are  present  along  the  colon,  whose  wall 
is  usually  much  thickened.  Meteorism  is  often  marked. 
In  the  severer  cases  the  number  of  stools  is  very  great  and 
the  amount  of  blood  considerable.  Fever  and  vomiting 
are  also  common. 

In  ulcerative  colitis  the  same  clinical  phenomena  are 
presented,  but  there  is  no  history  of  a  preceding  attack  of 
acute  dysentery. 

Diagnosis. — In  the  presence  of  the  symptoms  just 
described,  after  an  acute  dysenteric  attack  the  diagnosis 
is  clear.  The  passage  of  large  quantities  of  mucus,  blood, 
and  pus,  tenderness  and  resistance  along  the  colon,  diarrhoea, 
and  sometimes  tenesmus,  point  to  the  presence  of  ulcerative 
colitis.  From  haemorrhoids  both  conditions  are  distinguished 
by  the  diarrhoea  and  the  purulent  discharge.  From  new 
growth  the  diagnosis  is  often  difficult,  but  the  great  extent 
of  the  iniiltration  and  thickening  of  the  bowel  will  be 
evidence  against  this. 

INDICATIONS  FOR  OPERATION. 

If  the  methods  of  treatment  which  are  advocated  for 
obstinate  and  advanced  ulcerative  lesions  of  the  bowel  are 
ineffectual,  if  the  patient  is  steadily  losing  strength  and 
there  is  much  suffering,  surgical  intervention  is  called  for 
with  a  view  to  giving  rest  to  the  affected  portion 
of  bowel. 

The  methods  which  have  so  far  been  employed  are  the 
temporary  establishment  of  an  artiftcial  anus  at  the  caecum 
or  near  it,  or  the  performance  of  an  entero-anastomosis 
excluding  the  affected  bowel.  Occasionally  portions  of  intes- 
tine have  been  resected.  The  artificial  anus  has  been  closed 
after  a  period  varying  from  six  weeks  to  two  and  a  half 
years  ;    in  some  cases,  however,  it  has  not  been  possible  to 


DISEASES    OF    THE    INTESTINES.  215 

close  it  even  after  several  years.     Operation  should  not  be 
resorted  to  until  other  methods  have  been  tried. 

Prognosis. — Results  of  operation. — Colostomy  is  an  opera- 
tion not  entirely  free  from  risk,  and  resection  is  much  more 
dangerous. 

A  considerable  number  of  cases  have  been  operated  on^ 
Hermann's  recent  statistics  include  50 — most  of  them  with 
good  results.  Twenty-four  of  these  cases  were  cured  and 
eleven  relieved.  The  artilicial  anus  cannot  be  closed  for 
several  months  at  the  earliest,  the  time  varying  considerably, 
as  has  already  been  remarked.  Ewald,  Korte,  and  others 
have  reported  unsuccessful  cases,  and  probably  several 
others  have  not  been  recorded  in  which  no  improvement  or 
only  the  relief  of  a  single  symptom,  such  as  pain,  was 
obtained.     Six  fatal  cases  are  on  record. 

Without  operation. — The  prognosis  of  chronic  ulcerative 
lesions  of  the  colon  is  extremely  grave  in  the  average  case. 
Ancemia,  persistent  suffering,  and  wasting  usually  end  in 
death  after  a  long,  trying  illness.  The  apparently  cured 
often  relapse. 

LITERATURE. 

Boas.  Colitis  Ulcerosa.  Deut.  med.  Wochens.,  1903,  No.  11 ; 
and  Vereinsbeilage,  p.  50. 

Ewald.  Klinik  der  Verdauungskrankheiten,  Teil  iii.  Berlin, 
1902. 

Giordano.     Rivista  Venet.  di  Scienze  Mediche,     901. 

Hermann.  Chronische  Entzundungsprozessen  des  Dickdarms. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,   1904. 

Kartulis.  Dysenterie.  Nothnagel's  Handbuch  d.  spez.  Pathol., 
1898. 

Labey-Quenu.  De  ITntervention  Chirurgicale  dans  les  Formes 
Graves  des  Colites  Rebelles.     Paris,  1902. 

Murray.     Annals  of  Surgery,   1901. 

Xothnagel.  Krankheiten  des  Darmes  und  des  Peritoneums, 
2nd  Ed.,  1903. 

Orsini.     Rivista  Venet.  di  Scienze  Mediche,   1896. 

Summers.     Jour.  Amer.  Med.  Assoc,  July,  1903. 


MUCOUS    COLITIS    AND    MEMBRANOUS    ENTERITIS. 

Etiology  aND  Pathological  Anatomy. — The  disease 
is  far  more  common  in  women  than  men,  and  occurs 
especially  in  "  nervous "  individuals.  Diseases  of  the 
female  genital  organs  and  chronic  constipation  are  important 


2i6  INDICATIONS    FOR    OPERATION    IN 

etiological  factors.  Membranous  enteritis  not  infrequently 
follows  irrigation  of  the  bowel  with  irritating  fluids,  solutions 
of  alum,  tannin,  nitrate  of  silver,  etc.  Hitherto  little  has 
been  recorded  on  the  pathological  anatomy  of  the  disease  ; 
usually  there  are  no  recognizable  signs  of  intestinal 
inflammation. 

Clinical  Course. — The  different  types  have  one  symptom 
in  common,  the  passage  of  mucomembranous  masses  ; 
these  often  take  the  form  of  tubular  masses  of  coagulum  of 
a  greyish  white  colour  ;  in  other  cases  these  are  merely 
shreds  and  ribands.  The  passage  of  these  masses  occurs 
usually  at  intervals,  and  is  accompanied  by  much  pain  ;  the 
intervals  between  attacks  vary,  sometimes  extending  to  a 
month.  Constipation  is  usual  in  these  cases,  even  in  the 
intervals  when  no  mucus  is  passed.  In  other  cases  the 
passage  of  membrane  is  continuous  but  painless,  the  patients 
suffering  alternately  from  constipation  and  diarrhoea. 

Diagnosis. — The  passage  of  the  membranous  material 
is  sufficient  to  show  the  nature  of  the  disease.  From  simple 
catarrh  with  mucous  discharge  it  is  differentiated  by  this 
passage  of  membrane  and  in  some  cases  by  the  recurrence 
of  attacks. 

INDICATIONS   FOR  OPERATION. 

In  several  cases  an  artificial  anus  has  been  established  and 
the  colon  irrigated.  In  other  cases  intestinal  adhesions 
have  been  separated,  or  a  uterus,  fixed  in  a  position  of  retro- 
version, has  been  rectified. 

The  affection  itself  is  not  so  troublesome  or  dangerous  as 
to  justify  as  a  rule  any  operation  of  a  serious  nature.  The 
number  of  cases  so  far  operated  on  is  not  sufficiently  large 
for  the  formulation  of  any  definite  indications. 

Certainly  operation  should  only  be  advised  as  a  last 
resource  when  medical  treatment  has  entirely  failed,  when 
the  sufferings  are  intolerable,  and  when  the  patient  desires 
it  although  informed  of  the  inconveniences  of  an  artificial 
anus. 

Prognosis. — Results  of  operation. — In  several  cases,  the 
first  of  which  was  reported  by  Franke  in  1891,  complete 
cure  has  been  obtained  by  operation,  but  sometimes  after 
a  long  period  of  relief  the  attacks  have  recurred.  Gant 
considers   that   colostomy  hastens   cure  by   (a)  facilitating 


DISEASES    OF    THE    INTESTINES.  217 

the  emptying  of  the  bowel  and  avoiding  constipation  ; 
(b)  Making  it  possible  to  keep  the  intestine  thoroughly 
clean  with  irrigation,  and  to  apply  suitable  lotions. 

Without  operation. — In  many  cases  recovery  occurs  with- 
out treatment,  or  after  internal  or  local  treatment.  The 
affection  is  not  associated  with  any  serious  complications. 

LITERATURE. 

Delbet.     Traite  de  Chirurgie,  Vol.  viii.,    1899. 

Douglas.  Membranous  Colitis.  Jour.  Amer.  Aled.  Assoc.,. 
Aug.  31,  Vol.  xxvii. 

EiNHORN.  Membranose  Enteritis.  Arch.  f.  Verdauungskrank- 
heiten,  Bd.  iv. 

Froussard.  Contribution  a  I'Etude  de  I'Entero-Colite  Muco- 
membraneuse.     These  de  Paris,    1900. 

Gant.     Diseases  of  the  Rectum  and  Anus. 

Hale  White  and  Golding  Bird.  Brit.  Med.  Jour.,  1902, 
Vol.  i.,  p.  1337. 

Nothnagel.  Krankheiten  des  Darmes  und  des  Peritoneums. 
2nd  Ed.,   1903. 


EMBOLUS   AND   THROMBOSIS   OF   THE   MESENTERIC 

VESSELS. 

Etiology. — Embolus  of  the  mesenteric  arteries  is  as  a 
rule  associated  with  endocarditis  or  thrombus  formation  in 
the  heart.  Thrombosis  of  the  arteries  occurs  in  connection 
with  atheromatous  changes.  Thrombosis  of  the  mesenteric 
veins  may  be  the  result  of  any  of  the  conditions  which  cause 
thrombosis  in  the  portal  system.  The  affection  occurs  as  a 
rule  in  middle  and  advanced  age. 

Pathological  Anatomy. — Embolus  occurs  more  fre- 
quently in  the  superior  mesenteric  artery  than  in  the 
inferior,  the  proportions  in  86  cases  being  yy  :  9  (Neutra). 
The  block  may  be  partial  or  complete.  The  portion  of 
bowel  and  mesentery  supplied  by  the  obliterated  vessel  is 
engorged  and  infiltrated  with  blood,  and  there  is  blood  also 
in  the  bowel.  If  the  condition  persists,  more  or  less 
extensive  necrosis  of  the  intestinal  wall  results.  The 
anatomical  changes  are  the  same  in  thrombosis  of  the  veins 
as  in  embolus  of  the  arteries.  Sometimes  obliterating 
endarteritis  is  the  cause  of  embolic  or  thrombotic  ulcers 
of  the  intestine. 

Clinical  Course. — In  many  cases  tlic  affection  begins 


2i8  INDICATIONS    FOR    OPERATION    IN 

suddenly,  with  colic-like  pains,  which  may  be  either  diffuse 
or  localized  ;  vomiting  and  diarrhoea  follow,  and  the  stools 
later  contain  blood.  The  amount  of  blood  passed  is  often 
very  large,  and  the  general  signs  of  severe  haemorrhage  are 
then  present.  After  an  interval  of  one  to  two  days  the 
abdomen  becomes  tender,  the  pain  increases,  and  fluid  is 
found  in  the  peritoneal  cavity,  all  the  signs  of  peritonitis 
developing.  In  other  cases  the  signs  of  acute  bowel 
obstruction  predominate  :  neither  faeces  nor  flatus  are 
passed  ;  vomiting  is  repeated,  at  first  of  stomach  contents, 
then  blood,  and  then  faeces.  The  clinical  phenomena  of 
arterial  and  of  venous  obstruction  are  identical. 

Diagnosis. — The  occurrence  of  haemorrhage  from  the 
bowel  which  has  no  other  obvious  cause,  in  a  patient  who 
has  some  condition  which  leads  to  embolism,  such  as 
endarteritis,  has  in  many  cases  led  to  correct  diagnosis. 
This  will  be  particularly  confident  if  there  are  signs  of 
embolism  in  other  organs,  and  if  intense  abdominal  pain 
accompanies  or  precedes  the  haemorrhage.  The  tempera- 
ture is  low.  In  one  of  my  cases  the  abdominal  symptoms 
were  preceded  by  embolism  of  the  artery  of  the  sylvian 
fossa  and  of  one  radial  artery ;  in  another  case  there 
were  signs  of  splenic  and  renal  embolism.  If  symptoms 
of  peritonitis  develop,  the  diagnosis  is  still  further 
supported. 

In  atypical  cases  there  may  be  great  difficulties.  If 
there  is  no  haemorrhage  it  may  be  impossible  to  exclude 
acute  intestinal  obstruction  from  internal  hernia,  volvulus, 
and  other  causes.  In  intussusception  the  onset  is  usually 
not  so  extremely  acute  ;  and  a  tumour  is  usually  palpable. 
Gall-stone  obstruction  is  associated  with  a  history  of  long- 
continued  antecedent  colic. 

In  the  early  stages  of  hepatic  cirrhosis  there  is  often 
haemorrhage  from  the  bowel,  but  there  is  no  pain. 

INDICATIONS    FOR    OPERATION. 

Some  authors  advise  operation  as  early  as  possible,  and 
either  resection  or  the  formation  of  an  artificial  anus. 
Most  of  the  cases  operated  on  (under  mistaken  diagnosis) 
have,  however,  terminated  fatally  soon  after,  so  that  actual 
experience  points  to  the  inadvisability  of  recommending 
operation  if  the  diagnosis  is  definite.     There  is  a  chance, 


DISEASES    OF    THE    INTESTINES.  219 

even  though  only  a  small  one,  that  the  process  may  recover 
spontaneously.  Also  the  affection  usually  occurs  in 
individuals  who  are  wholly  unequal  to  the  strain  of  a 
serious  operation.  In  only  a  very  small  number  of  cases 
has  operation  been  followed  by  good  results. 

Prognosis. — Without  operation.  The  acute  cases  usually 
end  fatally  in  the  course  of  a  few  hours  or  days  ;  other 
cases  run  a  subacute  or  chronic  course,  and  the  fatal 
termination  may  be  delayed  for  several  weeks.  In  some 
cases,  when  only  the  branches  are  blocked  and  not 
the  main  mesenteric  artery,  recovery  follows.  Of  120 
cases  collected  by  Neutra,  12  recovered  and  108  died. 
The  following  case  of  recovery  came  under  my  own 
observation. 

A  man,  aged  twenty-three,  developed  signs  of  endo- 
carditis after  an  attack  of  articular  rheumatism.  There 
was  a  systolic  bruit  at  the  apex,  and  the  second  sound  was 
reduplicated.  The  temperature  was  high.  Enlargement 
•of  the  spleen  developed  suddenly,  and  then  diarrhoea  with 
tenesmus.  One  stool  contained  a  large  quantity  of  blood 
and  mucus,  and  there  was  great  abdominal  pain,  without 
meteorism  or  ascites.  On  the  next  day  there  was  tenderness 
on  pressure  over  the  left  lower  part  of  the  abdomen,  particu- 
larly between  the  navel  and  the  left  anterior  superior  spine. 
Diagnosis  :  embolus  of  the  inferior  mesenteric  artery. 
Some  days  later  there  were  signs  of  embolic  infarct  of  the 
left  kidney.  All  the  symptoms  gradually  improved  except 
the  heart  condition,  which  remained  unchanged. 

LITERATURE. 

Neutra.  Ueber  die  Erkrankungen  der  Mesenterialgefasse. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1902. 

NoTHNAGEL.  Erkrankungcn  des  Darmes  und  des  Peritoneums. 
2nd  Ed.,  1903. 

Deckart.  Thrombose  u.  Embolic  der  Mesenterialgefasse. 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.,   1900. 

Elliot.     Annals  of  Surgery,  1895. 

Borszeky.  Ileus  durch  Embolic  der  Art.  Mesent.  Super.  Beitr. 
■/..  klin.  Chir.,  1901. 

Kabartschieff.  Thrombose  Mesenteriquc.  These  de  Mont- 
pellier,  1899. 

Watson.     Boston  Med.  and  Surg.  Jour.,  1894. 

Gallavardin.  Embolics  et  Thromboses  des  Vaisseaux  Mcsen- 
•tcriqucs.    Gaz.  des  Ffojiit..  r90i. 


220  INDICATIONS    FOR    OPERATION    IN 

HAEMORRHOIDS. 

Etiology. — The  most  important  etiological  factors  of 
haemorrhoids  are  habitual  constipation,  general  venous 
stasis  from  diseases  of  the  heart,  lungs,  and  liver,  and  local 
stasis  from  affections  of  the  pelvic  organs.  Men  are  more 
frequently  affected  than  women,  especially  middle-aged 
men  with  sedentary  occupations. 

Pathological  Anatomy. — The  condition  is  one  of 
varicosity  of  the  haemorrhoidal  veins.  External  and 
internal  haemorrhoids  are  distinguished,  but  the  anatomical 
difference  is  only  one  of  covering,  the  former  being  covered 
by  the  skin  of  the  anal  canal,  the  latter  by  mucous  membrane. 

Clinical  Signs. — External  haemorrhoids  cause  little 
trouble  beyond  itching  ;  they  may  attain  the  size  of  a 
hazel  nut  and  have  a  broad  base.  If  inflammatory  throm- 
bosis takes  place,  there  is  great  pain  and  sensation  as  of 
a  foreign  body,  and  the  nodes  become  tense  and  firm  to 
the  touch.  The  attack  of  phlebitis  either  subsides  in  a  few 
days,  or  suppuration  takes  place  and  may  eventuate  in  an 
ulcer  or  a  fissure.  Internal  haemorrhoids  are  sometimes 
single,  sometimes  arranged  circularly  in  one  or  more  groups. 
The^'  frequently  bleed  ;  this  may  take  place  either  after 
or  independently  of  defiecation,  and  may  be  profuse  and 
persistent.  Haemorrhoids  often  prolapse  through  the  anus- 
and  may  become  strangulated  ;  the  pain  then  is  intense, 
is  associated  with  fever,  and  sometimes  with  retention  of 
urine,  and  even  symptoms  of  intestinal  obstruction.  The 
attack  often  ends  in  gangrene,  and  abscess  and  fistula  may 
result.  Rectal  catarrh,  with  excessive  discharge  of  mucus 
and  tenesmus,  usually  accompanies  such  an  attack. 

Diagnosis. — Simple  inspection  reveals  the  presence  of 
external  and  also  of  prolapsed  internal  haemorrhoids  ;  if 
not  prolapsed,  the  latter  are  discoverable  by  palpation  and 
the  use  of  the  speculum.  Without  proper  examination 
internal  haemorrhoids  may  be  confounded  with  carcinoma, 
rectal  polypi,  and  syphilitic,  gonorrhoeal,  or  tuberculous 
ulceration.  In  dysentery  there  is  tenesmus,  and  blood  in 
the  motions,  as  in  haemorrhoids,  but  the  blood  is  more  or  less- 
altered,  and  there  are  tissue  fragments  also  in  the  faeces. 
In  chronic  rectal  catarrh  without  haemorrhoids  there  is  nO' 
blood  passed. 


DISEASES    OF     THE    INTESTINES.  221 

INDICATIONS    FOR    OPERATION. 

External  haemorrhoids  require  operation  if  they  are  a 
continual  source  of  trouble  from  inflammatory  attacks, 
fissure,  eczema,  etc.  The  suppurative  complications  must 
be  treated  by  incision,  and  fissures  which  do  not  yield  to 
treatment  with  ointment  require  forcible  dilatation  of  the 
sphincter  and  incision. 

Internal  haemorrhoids  call  for  radical  operation  when 
they  occasion  repeated  and  considerable  loss  of  blood, 
when  they  easily  and  often  become  prolapsed  and  are 
difficult  to  reduce  or  irreducible,  and  when  they  become 
inflamed  or  give  rise  to  pain  in  defsecation.  There  cannot 
be  said  to  be  any  contra-indication  to  operation.  The 
operations  practised  to-day  are  free  from  risk.  The  patient 
is  often  unable  to  pass  water  for  a  day  or  so,  and  the  first 
evacuations  are  painful.  Cicatricial  narrowing  of  the  anus 
is  very  rare,  but  it  has  occasionally  been  recorded  after 
radical  excision,  which  is  also  usually  associated  with  a 
considerable  loss  of  blood.  The  results  of  operation  are 
good  ;  the  percentage  of  unsuccessful  cases  only  reaches 
2  to  3  per  cent. 

Prognosis. — Without  operation. — Prolonged  haemorrhage 
may  give  rise  to  serious  symptoms  and  even  prove 
fatal.  A  case  under  my  own  observation  was  brought  to 
hospital  moribund,  and  the  autopsy  showed  the  cause  of 
death  to  be  haemorrhage  from  an  internal  haemorrhoid. 
As  already  stated,  haemorrhoids  are  often  complicated  by 
suppurative  inflammation,  fissures,  and  fistulae.  Deep-seated 
periproctitis  and  proctitis  are  also  common  sequelae,  and 
not  uncommonly  a  troublesome  eczema. 

LITERATURE. 

XoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.,  1903. 

F.\LKE.  Endresultate  der  Langenbeck'schen  Operation.  Beitr.  z. 
klin.  Chir.,  Bd.  xxxiii. 

Reixbach.  Die  Excision  der  Haemorrhoiden.  Beitr.  z.  klin. 
Chir.,  Bd.  xxiii. 

Rotter.  Haemorrhoiden.  Handbuch  der  prakt.  Chir.  MickuUcz, 
Bruns,  u.  Bergmann.     2nd.  Ed.,  Bd.  iii.,  1903. 

GooDSALL  and  Miles.  Diseases  of  the  Anus  and  Rectum, 
Pt.  I.,  p.  251.      1900. 

Ga.n't.     Diseases  of  the  Rectum  and  Anus. 


222  INDICATIONS    FOR    OPERATION    IN 

PoTARCA.  Nouveau  Procede  Operatoire  des  Hemorrhoides.  Rev. 
de  Chir.,  No.  5,  1902. 

ViRDiA.  La  Cura  Chirurgica  delle  Emoroidi.  Gaz.  Internat. 
di  Med.  Practica,  Nos.  12  &  20,  IQ02. 


PROCTITIS. 

Etiology.— Common  causes  of  proctitis  are  constipation 
and  impaction  of  fjcces,  irritating  enemata,  foreign  bodies, 
and  oxyurides.  The  disease  may  also  arise  from  a  gonor- 
rhoea!, syphihtic,  or  dysenteric  infection,  and  as  a  comphca- 
tion  of  carcinoma  and  haemorrhoids. 

Pathological  Anatomy. — The  mucous  membrane  may 
simply  show  catarrhal  changes,  swelling  oedema,  and 
hyperaemia,  or  there  may  be  ulceration,  sometimes  very 
extensive.  Not  infrequently  infection  spreads  to  the 
cellular  tissue  around,  and  a  purulent  periproctitis  results. 

Clinical  Course. — In  catarrhal  proctitis  the  stools  are 
frequent  and  often  fluid  ;  there  is  tenesmus  and  also  pain 
in  the  intervals  between  the  stools.  A  considerable  quantity 
of  mucus  is  passed,  and  often  pus  and  blood  also.  The 
rectum  is  extremely  tender  to  digital  exploration.  In 
many  instances  the  patient  also  suffers  from  retention  of 
urine  and  strangury.  After  the  condition  has  continued 
for  some  time  there  may  be  some  inefficiency  of  the 
sphincter.  Fever  and  general  weakness  usually  accompany 
the  attack,  which  varies  in  severity  and  acuteness. 

Diagnosis. — The  signs  and  symptoms  enumerated 
should  be  sufficient  for  a  diagnosis,  together  with  a  careful 
digital  exploration,  and  in  some  cases  examination  with 
the    speculum. 

Inspection  differentiates  the  condition  from  haemor- 
rhoids and  anal  fissure  ;  in  carcinoma  the  mucous 
membrane  is  felt  to  be  infiltrated  with  firm  growth  ; 
in  tuberculous  ulceration  greyish  nodules  are  seen  at  the 
margins  of  the  ulcers,  and  the  discharge  contains  tubercle 
bacilli.  The  history  will  distinguish  an  attack  of  acute 
dysentery.  Tabetic  crises  are  recognized  by  the  presence 
of  other  tabetic  symptoms. 

INDICATIONS    FOR    OPERATION. 

In  acute  proctitis  operative  treatment  is  only  necessary 
when  there  is  some    complicating   purulent  process   (peri- 


DISEASES    OF    THE    INTESTINES.  223 

proctitis),  or  when  the  rectal  inflammation  is  secondary  to 
some  other  condition  which  requires  operation.  In  chronic 
proctitis  operation  has  in  some  cases  been  undertaken  to 
give  the  inflamed  canal  complete  rest  by  means  of  colo- 
tomy.  This  is  unnecessary  until  other  therapeutic  measures 
have  been  tried  and  failed,  and  unless  the  symptoms  are 
intolerably  distressing.  Operation  tlierefore  should  be 
considered  rather  as  a  last  resource.  Stricture  sometimes 
follows  proctitis,  and  if  this  cannot  be  satisfactorily  treated 
by  bougies,  operation  is  called  for. 

Prognosis. — In  a  not  inconsiderable  number  of  cases 
the  rest  provided  by  a  colostomy  is  successful  in  bringing 
about  cure.  The  operation  is  not  of  course  a  severe  one, 
but  not  entirely  free  from  risk.  Without  operation  chronic 
proctitis  often  proves  very  obstinate.  In  some  cases  it 
leads  to  paresis  of  the  sphincter,  prolapse  of  the  rectum, 
cicatricial  stricture,  periproctitis,  or  haemorrhoids. 

LITERATURE. 

Arcoleo.  Sulla  Rectite  Ipertrofica  Proliferante.  II  Morgagni, 
Bd.  ii.,  Feb.,  1901. 

Beach.     Recto-Colitis.     Med.  News,  Dec.  14,  1901. 

Giordano.     Rivista  Venet.  di  Sci.  Med.,  1901. 

Hermann.  Versuche  chirurgischer  Behandlung  von  chron. 
Entziindungsprozessen  des  Dickdarmes.  Centralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chir.,  1904. 

Labey-Quenu.  De  ITntervention  Chirurgicale  dans  les  Formes 
Graves  des  Oolites  Rebelles.      1902. 

MuRR.w.     Annals  of  Surgery,  Vol.  xxxiii.,  1901. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.,  1903. 


CHAPTER    XV. 

Diseases    of    the    Intestines 

{continued). 


15 


12-J 


Chapter    XV. 
DISEASES    OF    THE    INTESTINES    (contd.). 

INTESTINAL    STRICTURE. 

Etiology  and  Pathological  Anatomy. — Intestinal 
stricture  is  caused  by  a  variety  of  processes  ;  by  cicatricial 
contraction  after  ulceration  of  a  tuberculous,  dysenteric, 
catarrhal,  or  syphilitic  nature  ;  by  torsion  of  the  small  or 
large  bowel  without  complete  obstruction ;  by  internal 
herniation  into  a  peritoneal  recess  ;  by  kinking  following 
the  formation  of  adhesions.  Progressive  obstruction  by 
scybala,  by  gall-stones,  and  by  chronic  invagination 
dependent  on  tumours,  are  considered  elsewhere. 

In  all  cases  of  chronic  intestinal  stricture  the  bowel 
below  the  stenosis  is  empty,  while  above  it  is  distended, 
though  rarely  to  an  extreme  extent  when  there  is  no  acute 
obstruction.  Above  the  stenosis  the  muscular  wall  is 
hypertrophied,  the  mucosa  and  submucosa  inflamed  and 
often  ulcerated  (the  distension  ulceration  of  Kocher). 
This  complication  may  lead  to  secondary  peritonitis, 
diffuse  or  localized. 

Clinical  Course. — Patients  with  stricture  of  the  colon 
and  rectum  as  a  rule  exhibit  as  the  first  symptom  chronic 
constipation,  which  becomes  more  and  more  rebellious  and 
is  accompanied  by  a  sensation  of  fullness  in  the  abdomen. 
Sometimes  the  constipation  is  replaced  by  diarrhoea  for  a 
short  period,  reappearing  afresh  and  in  an  aggravated  form. 
There  are,  however,  cases  of  stricture  of  the  large  bowel 
who  complain  of  no  irregularity  in  the  motions. 

In  stricture  of  the  small  bowel,  the  stage  of  constipation 
is  often  absent.  In  stricture  in  this  situation,  as  also  in 
stricture  of  the  colon,  there  occur  attacks  of  colic,  and. 
this  may  be  the  first  symptom.  The  pain  is  intense 
during  the  attack,  passes  off  with  gurgling,  is  often  referred 


228  INDICATIONS    FOR    OPERATION    IN 

to  the  same  spot,  and  usually  accompanied  by  nausea,  and 
sometimes  vomiting.  If  an  attack  lasts  for  some  time, 
the  patient  during  its  presence  passes  neither  flatus  nor 
faeces.  The  most  characteristic  sign  accompanying  the 
attacks  is  exaggerated  peristalsis  ;  the  intestinal  coils  are 
observable  through  the  parietes,  and  are  palpable  and  firm 
to  the  touch,  owing  to  the  tetanic  contraction  of  their 
muscular  fibres.  This  intestinal  spasm  persists  from  a 
few  seconds  to  a  minute  or  two,  and  then  passes  off,  to  recur 
later. 

Sometimes  the  interval  between  two  attacks  is  long, 
even  several  weeks,  but  this  is  in  the  early  stage  of  the 
stenosis,  and  as  time  goes  on  the  period  of  exemption 
becomes  shorter,  until  finally  the  pains  are  never  entirely 
absent,  the  abdomen  is  persistently  distended,  and  the 
spasmodic  seizures  occur  several  times  a  day. 

There  is  often  mucus  in  the  stools,  and  chronic  diarrhoea 
is  not  unusual.  In  some  forms  of  stricture,  pus  and  blood 
are  also  present  in  the  motions,  that  is  to  say  in  strictures 
due  to  new  growth,  invagination,  and  dysenteric  ulceration  ; 
in  other  types  these  are  usually  absent. 

Splashing,  and  even  a  metallic  percussion  note,  can  often 
be  elicited  over  the  distended  bowel  above  the  stricture. 

Diagnosis. — If  attacks  of  colic  occur  from  time  to  time, 
accompanied  by  visible  and  palpable  spasmodic  contracture 
of  the  bowel,  if  the  spasm  passes  off  to  the  accompaniment 
of  borborygmi,  and  if  the  history  is  suggestive  of  intestinal 
stenosis,  then  a  diagnosis  of  "  intestinal  stricture  from 
organic  lesion  "  will  be  made.  If  the  stricture  is  in  the 
rectum  the  diagnosis  will  be  made  by  palpation.  The  form 
of  the  motions  is  not  characteristic  in  bowel  stricture  ; 
ribbon-like  stools  may  be  passed  without  any  anatomical 
stenosis  ;  blood,  pus,  and  mucus,  if  present,  will  aid  the 
diagnosis.  Discrimination  must  be  exercised  with  regard 
to  the  interpretation  of  constipation  ;  when  due  to  stricture 
its  onset  is  somewhat  sudden,  there  is  an  absence  of  other 
ascertainable  cause,  such  as  neurasthenia,  change  in  habits 
of  life,  or  diet,  preceding  acute  intestinal  catarrh,  etc., 
and  it  is  associated  with  anaemia,  general  weakness,  and 
wasting. 

The  diagnosis  may  be  aided  by  a  history  of  some 
antecedent    condition   liable   to   cause    stenosis,     such   as 


DISEASES    OF    THE    INTESTINES.  229 

parametritis,  cholecystitis,  local  or  general  peritonitis, 
appendicitis,  or  a  reduced  hernia,  or  some  bowel  affection 
liable  to  be  followed  by  stricture,  such  as  tuberculosis, 
dysentery,  and  syphilis. 

With  regard  to  the  diagnosis  of  the  site  of  the  stenosis, 
distension  of  the  upper  part  of  the  abdomen  and  of  the 
flanks  points  to  obstruction  low  in  the  colon,  i.e.,  in  the 
pelvic  colon.  Distension  of  the  right  flank  only  points  to  a 
situation  high  in  the  colon.  The  distended  and  hypertro- 
phied  colon  is  distinguished  from  small  bowel  by  its  size. 
In  stricture  of  the  small  intestine  the  centre  of  the  abdo- 
men is  distended  and  the  flanks  are  empty,  and  abnormal 
peristalsis  of  small  coils  lying  parallel  to  one  another  is  often 
seen.  Percussion  similarly  will  aid  in  localizing  the  seat 
of  obstruction  and  demonstrating  the  distended  bowel 
above  it  by  a  highly  resonant  metallic  note. 

Peristalsis  and  intestinal  spasm  often  indicate  the  position 
of  the  obstruction,  but  only  so  at  the  commencement  of  an 
attack  ;  after  the  state  of  spasm  has  existed  for  some  days 
it  diffuses  from  its  point  of  commencement  and  extends 
elsewhere. 

Regarding  the  anatomical  nature  of  the  lesion,  the 
following  facts  should  be  noted.  If  there  is  a  hernia  of  old 
standing,  a  connection  between  it  and  the  intestinal 
stenosis  must  be  considered  probable  unless  some  other 
cause  is  plainly  present  (Nothnagel).  If  there  is  a  history 
pointing  to  gall-stones,  gall-stone  ileus  will  be  suspected. 
An  acute  onset  in  a  previously  healthy  patient  suggests 
a  twist,  in  children  under  the  age  of  ten  intussusception. 
If  fever  develops  during  the  first  few  hours  of  illness,  acute 
peritonitis  will  be  suspected. 

Differential  Diagnosis. — From  meteorism  from  other 
causes,  and  from  affections  with  violent  peristalsis  without 
anatomical  obstruction,  intestinal  stricture  is  distinguished 
by  the  very  pronounced  and  repeated  colic,  with  spasm  of 
the  distended  coils.  Sometimes  there  is  a  possibility  of 
mistaking  the  dilated  coils  filled  with  liquid  and  gas  for 
ascites,  seeing  that  change  of  position  may  produce  a  very 
marked  change  in  percussion  note.  I  have  myself  diagnosed 
ascites  and  intestinal  stenosis  in  a  case  in  which  operation 
showed  no  free  fluid  in  the  peritoneal  cavity.  In  such 
cases,  according  to  Nothnagel,  the  production  of  splashing 


230  INDICATIONS    FOR    OPERATION    IN 

"by  rapid  percussion  of  an  area  giving  a  dull  note   shows 
the  presence  of  fluid  within  bowel. 

INDICATIONS    FOR    OPERATION. 

If  the  clinical  signs  point  definitely  to  the  presence  of  a 
chronic  or  acute  bowel  stenosis,  and  if  the  symptoms 
(colic,  with  painful  spasmodic  contractions)  indicate  an 
anatomical  stenosis,  there  is  a  strict  indication  for  operative 
interference.  This  is  true  whatever  the  cause  of  the  stenosis 
may  appear  to  be.  Fsecal  obstruction  alone,  with  its 
consequences,  requires  no  operation. 

In  suspected  gall-stone  ileus  it  is  often  justifiable  to 
temporize.  The  time  for  operation  is  as  soon  as  the 
diagnosis  is  definitely  made  ;  after  this  temporizing  does 
not  alter  the  indications,  and  a  risk  is  run  of  the  onset 
of  acute  intestinal  obstruction,  when  the  prognosis  of 
operation  will  be  much  worse.  The  operations  practised 
are  :  exclusion  of  the  stenosis  by  entero-anastomosis 
between  the  coils  above  and  below ;  resection,  particu- 
larly in  the  case  of  tumours  and  intussusceptions  ; 
reposition  of  the  bowel  in  volvulus  ;  freeing  of  the  gut  in 
kinking  by  adhesions.  If  the  obstacle  cannot  be  removed 
or  short  circuited,  an  artificial  anus  is  necessary. 

Contra-indications. — If  the  general  condition  is  bad  in 
consequence  of  some  other  complicating  affection,  and  the 
intestinal  stricture  is  causing  symptoms  of  a  comparatively 
slight  degree  of  severity,  then  the  patient  may  be  advised 
against  operation  if  the  complication  is  one  that  will 
necessarily  prove  fatal.  A  bad  general  condition  in  itself 
is  no  contra-indication,  as  in  the  worst  cases  an  artificial 
anus  may  be  established  under  local  ansesthesia. 

If  the  chronic  obstruction  is  due  to  faecal  impaction, 
operation  is  not  necessary,  as  this  can  be  dealt  with  by 
non-operative  measures.  If  definite  diffuse  peritonitis  is 
present,  along  with  signs,  symptoms,  and  history  pointing  to 
stenosis,  operation  will  almost  certainly  be  soon  followed 
by  death,  and  is  therefore  as  a  rule  not  to  be  advised. 

Prognosis. — Of  operation. — In  many  cases  a  successful 
operation  is  followed  by  permanent  relief,  particularly  in 
the  case  of  entero-anastomosis  for  benign  strictures  and 
the  separation  of  adhesions  causing  kinking.  The  colic 
as  a  rule  disappears  entirely,  but  sometimes  not  until  a 


DISEASES    OF    THE    INTESTINES.  231 

considerable  interval  has  elapsed  ;  in  all  cases  it  is  much 
relieved  at  once.  If  an  artificial  anus  is  necessary,  this  is 
of  course  very  troublesome  to  the  patient  and  his  entourage. 
The  risks  of  operation  vary  with  the  procedure,  in  the  order — 
establishment  of  an  artificial  anus,  entero-anastomosis, 
resection. 

Without  operation. — Without  operation  the  patient 
gradually  gets  worse.  The  prognosis  as  to  time  varies 
according  to  the  cause  of  the  stenosis  and  the  secondary 
changes  in  the  bowel.  A  case  of  simple  cicatricial  stric- 
ture will  live  longer  than  a  case  where  the  stenosis  is  due 
to  new  growth.  Sudden  dangerous  complications  are  not 
uncommon,  particularly  the  onset  of  acute  obstruction. 
A  stricture  which  is  not  very  narrow  may  be  blocked  by  a 
faecal  mass  or  a  fruit-stone.  After  the  stricture  has  been 
present  for  some  time  distension  ulcers  tend  to  develop 
above  it,  and  perforation  may  occur  ;  there  then  develops 
either  acute  diffuse  peritonitis  or  an  encysted  peritonitis, 
with  faecal  abscess  and  its  associated  risks. 

LITERATURE. 
Vide — Intestinal  Obstruction. 


INTESTINAL    OBSTRUCTION. 

Intestinal  obstruction,  or  ileus  (Schlange)  may  be  produced 
by  a  variety  of  different  anatomical  lesions  which  all  give 
rise  to  a  certain  group  of  symptoms,  of  which  the  following 
are  the  most  important  :  pain  in  the  abdomen,  constipation, 
vomiting  at  first  bilious  and  then  fjecal,  and  meteorism. 

Dynamic  obstruction,  the  result  of  paralysis  of  the 
intestinal  muscular  wall,  is  to  be  distinguished  from 
mechanical  obstruction  due  to  some  mechanical  cause. 
Cases  of  mechanical  obstruction  are  further  divided  into 
those  in  which  there  is  strangulation  and  those  in  which 
there  is  obturation  without  strangulation.  In  strangulation 
the  bowel  wall  suffers  damage  owing  to  interference  with 
its  circulation  ;  in  obturation  the  lumen  of  the  bowel  is 
obliterated  by  some  agent  either  within  or  without  the 
channel,  and  there  is  no  primary  damage  to  the  bowel  itself. 

Etiology  .\nd  Anatomy. — Obstruction  from  paralysis 
of  the  gut  is  most  commonly  the  consequence  of  acute 


232  INDICATIONS    FOR    OPERATION    IN 

peritonitis,  but  in  some  cases  the  paralysis  is  due  to 
mechanical  injury  to  the  bowel,  as  for  example  after  an 
extensive  abdominal  operation,  or  when  a  portion  of 
strangulated  bowel,  although  replaced,  is  unable  to  resume 
its  functions.  Intestinal  paralysis  from  toxic  infection  is 
uncommon. 

Strangulation  may  occur  in  a  variety  of  ways.  Bowel 
may  be  caught  by  peritoneal  adhesions,  or  by  an  adherent 
appendix  or  a  Meckel's  diverticulum,  or  may  be  herniated 
and  strangulated  through  the  diaphragm  or  in  one  of  the 
abdominal  fossae,  the  fossa  duodenojejunalis  for  example. 
The  ileum  is  usually  the  part  involved  under  these  circum- 
stances. Volvulus,  that  is  to  say  axial  torsion  of  bowel,  is 
particularly  common  in  the  pelvic  colon  ;  the  twisted  bowel 
is  strangulated  as  the  torsion  interferes  with  its  circulation. 
A  long  pelvic  colon  and  a  long  mesentery  predispose  to  the 
accident,  and  injury  or  constipation  may  lead  up  to  it. 

Intestinal  obturation  may  be  due  to  new  growths,  to 
kinking  by  peritoneal  adhesions,  or  to  cicatricial  stricture 
following  ulceration  (tuberculosis).  Tumours  of  neighbour- 
ing organs  may  obstruct  the  bowel  by  compression.  Gall- 
stones, faecal  masses,  and  other  foreign  bodies  may  also 
cause  the  condition.  Intussusception  is  another  cause 
which  is  considered  in  a  special  chapter. 

In  all  these  different  types  of  obstruction,  if  unrelieved, 
peritonitis  supervenes  and  is  the  usual  cause  of  death.  In 
the  distended  bowel  above  the  obstruction,  ulceration 
occurs  after  the  obstruction  has  persisted  for  some  time. 

I.  Intestinal  Paralysis  (dynamic  ileus). 

Clinical  Course. — When  intestinal  paralysis  follows 
peritonitis  the  distension  of  the  bowel  is  usually  very  great. 
The  amount  of  distension  varies  with  the  extent  of  the 
peritonitis.  In  the  acute  diffuse  form  the  distension  is 
extreme  ;  in  the  acute  circumscribed  the  meteorism  is  slight 
and  localized  and  the  intestinal  movements  are  not  com- 
pletely abolished.  In  acute  diffuse  peritonitis  there  is 
general  tenderness  on  pressure,  the  abdomen  is  barrel- 
shaped,  and  the  distension  is  uniform.  The  temperature 
is  often,  but  by  no  means  always,  raised.  By  examining 
the  abdomen  in  different  postures,  free  fluid  is  usually  to  be 
detected  early. 


DISEASES    OF    THE    INTESTINES.  233 

Diagnosis. — If  the  group  of  symptoms  mentioned  above 
is  present,  if  the  abdomen  is  distended  and  tender  to  pressure, 
and  if  there  are  signs  of  free  fluid  in  the  peritoneal  cavity, 
then  the  diagnosis  of  paralytic  obstruction  is  clear  ;  if  the 
abdomen  is  equally  distended  and  the  tenderness  is  diffuse, 
the  condition  is  one  of  general  peritonitis.  The  starting 
point  of  the  infection  can  at  this  stage  be  usually  judged 
only  from  the  history,  in  which  there  may  be  points 
suggesting  cholecystitis,  or  appendicitis,  or  some  affection 
of  the  female  genital  organs,  as  the  original  focus. 

From  obstruction  due  to  strangulation,  paralytic  ileus 
is  distinguished  by  the  inequality  of  the  distension  in 
strangulation,  and  the  fact  that  the  outline  of  a  single 
greatly  distended  coil  of  bowel  can  usually  be  recognized. 
In  obstruction  from  stricture  the  distension  is  also  unequal, 
abnormal  peristalsis  can  be  made  out,  and  the  bowel  above 
the  stricture  can  be  felt  rigid  and  hypertrophied.  The 
indications  for  operation  in  this  condition  of  paralytic 
obstruction  are  discussed  in  the  article  on  peritonitis. 

2.  Strangulation  (strangulation-ileus). 

Clinical  Course. — The  onset  is  usually  sudden,  with 
acute  pain,  often  collapse,  and  vomiting  of  bilious  matter. 
After  a  short  time  the  intestinal  functions  are  entirely 
suspended,  and  neither  faeces  nor  flatus  are  passed,  but 
just  at  first  fasces  in  small  amount  may  be  got  rid  of.  Soon 
the  contour  of  a  distended  bowel  coil  can  be  made  out, 
remaining  absolutely  immobile  and  not  tender  to  pressure. 
Even  in  the  cases  of  patients  with  thick  abdominal  walls 
this  coil  can  often  be  discovered  by  palpation.  Early 
effusion  into  the  peritoneal  cavity  is  usual.  In  volvulus 
of  the  pelvic  colon  a  small  quantity  of  water  only  (^  to  ^j 
litre)  can  be  passed  per  anum;  in  volvulus  of  the  small  bowel 
this  sign  is  not  present. 

Diagnosis. — The  mode  of  onset  and  the  discovery  of  a 
largely  distended  bowel  coil  often  enables  a  diagnosis  to  be 
made.  Sometimes  the  diagnosis  becomes  certain  when  a 
distended  coil  of  small  bowel  can  be  made  out  which  cannot 
be  easily  displaced  upwards,  and  which  extends  from  the 
pelvis  towards  the  upper  parts  of  the  abdomen  ;  and  in 
other  cases  the  impossibility  of  passing  any  considerable 
amount  of  fluid  ])er  anum  clears  up  the  diagnosis.     If  chronic 


234  INDICATIONS    FOR    OPERATION    IN 

intestinal  disturbance  has  followed  the  reduction  of  a  hernia, 
and  if  symptoms  of  obstruction  supervene  suddenly,  the 
obstruction  will  be  suspected  at  the  site  of  the  previous 
hernia. 

Examination  of  the  usual  hernial  orifices  will  exclude 
strangulation  of  an  external  hernia,  and  the  absence  of 
forcible   peristalsis   will   exclude   obstruction   by   stricture. 

In  general  peritonitis  there  is  universal  intestinal 
paralysis;  in  local  peritonitis  there  is  local  meteorism,  local 
tenderness  to  pressure,  often  fever,  and  seldom  faecal 
vomiting.  The  history  must  be  relied  upon,  along  with 
the  symptoms,  to  exclude  biliary  and  renal  colic.  In  some 
cases  the  differential  diagnosis  is  very  difficult  :  the  two 
following  cases  illustrate  this  : — 

An  advocate,  aged  fifty-four,  who  had  suffered  from 
heart  disease  for  several  years,  had  for  a  year  and 
a  1  half  had  attacks  of  constipation,  with  much  pain 
and  collapse.  The  attacks  had  become  more  frequent, 
though  not  more  serious.  The  first  occasion  on  which  I 
saw  the  patient  he  was  collapsed,  complained  of  nausea, 
and  had  a  small,  running  pulse.  Some  hours  previously 
pain  had  come  on  suddenly  and  acutely  in  the  left  lower 
portion  of  the  abdomen.  He  passed  neither  flatus  nor  faeces 
on  this  day  nor  the  two  following,  and  vomited  repeatedly. 
I  found  a  large  distended  coil  of  bowel,  which  seemed  to 
correspond  to  the  transverse  colon.  Rectal  irrigation  with 
large  quantities  of  water  was  possible  ;  there  was  no 
abnormal  peristalsis,  and  the  hernial  orifices  were  free. 
As  he  had  previously  suffered  from  uraturia  from  time 
to  time,  renal  calculus  was  thought  of,  in  spite  of  the 
absence  of  other  signs  of  renal  colic.  On  the  second  day 
fragments  of  red  cells  were  found  in  the  urine,  and  on 
the  third  he  passed  a  renal  stone  and  was  at  once  relieved 
of  all  his  obstruction  symptoms. 

A  woman,  aged  48,  was  brought  to  hospital  with  a 
diagnosis  of  subacute  nephritis  and  commencing  uraemia. 
She  was  collapsed,  almost  pulseless,  but  conscious,  and 
complained  of  acute  pain  in  the  neighbourhood  of  the  right 
costal  arch.  Vomiting  was  incessant.  During  the  following 
days  the  amount  of  urine  was  from  500  to  800  grams, 
neither  flatus  nor  faeces  were  passed,  the  vomiting  per- 
sisted,   increasing     distension    was    noticed    in    a   coil    of 


DISEASES    OF    THE    INTESTINES.  235 

intestine  in  the  right  lumbar  region  ;  no  abnormal  peristalsis, 
and  no  tenderness  on  pressure.  The  pain  had  com- 
menced suddenly  two  days  before  admission.  In  view  of  a 
commencing  pneumonia,  cardiac  weakness,  and  the  renal 
disease,  no  operation  was  deemed  advisable.  At  the 
autopsy  a  thick  omental  band  was  found  strangulating 
the  colon  in  the  region  of  the  hepatic  flexure,  and  there 
was  also  secondary  peritonitis. 

INDICATIONS    FOR    OPERATION. 

When  a  diagnosis  of  intestinal  strangulation  is  made, 
operation  is  advisable  at  once,  whether  the  site  of  strangu- 
lation can  be  determined  or  not.  If,  therefore,  symptoms 
of  obstruction  are  present,  and  a  large  distended  coil  of 
bowel  is  found,  immovable,  or  showing  only  slight  peristaltic 
movement,  then  laparotomy  should  be  done  forthwith. 
If  pain,  vomiting,  and  absolute  constipation  are  present, 
but  no  distended  intestinal  coil  can  be  discovered,  it  is 
justifiable  in  some  cases  to  temporize  until  the  second  day ; 
but  if  the  symptoms  still  persist,  an  exploratory  laparo- 
tomy must  then  be  done.  In  every  case  the  pulse  and  the 
general  condition  must  be  carefully  watched,  and  the  onset 
of  the  collapse  must  be  anticipated  by  operation.  The 
impossibility  of  passing  a  considerable  quantity  per  anum 
indicates  immediate  operation.  If  initial  serious  symptoms 
improve  during  the  subsequent  forty-eight  hours,  if  the 
pulse  becomes  stronger  and  less  rapid,  and  the  collapse, 
vomiting,  and  pain  diminish,  and  particularly  if  some  flatus 
or  faeces  are  passed,  it  is  well  to  temporize,  and  operate  only 
if  the  symptoms  relapse. 

If  when  the  patient  is  first  seen  the  abdomen  is  already 
much  distended,  but  there  are  definite  signs  of  slight 
peristaltic  movement  (some  coils  of  intestine  being  palpable) 
and  no  considerable  degree  of  ascites  :  operation  is  indicated 
if  the  history — sudden  onset  with  severe  pain  when  the 
patient  was  in  ordinary  health,  and  the  absence  of  physical 
signs  indicative  of  any  inflammatory  focus  in  the  abdominal 
cavity  (appendix,  pelvic  organs) — points  to  obstruction 
from  intestinal  strangulation  rather  than  peritonitis. 

The  object  of  operation  is  to  free  the  involved  bowel  by 
the  section  of  constricting  bands,  the  restoration  of  volvulus, 
etc.     When   there  is  great  distension   the  coils   are  often 


236  INDICATIONS    FOR    OPERATION    IN 

emptied  by  puncture.  Resection  of  bowel  is  only  done 
when  the  bowel  is  so  altered  by  the  strangulation  that  its 
recovery  is  considered  doubtful. 

If  there  be  pronounced  collapse  and  signs  of  general 
peritonitis  in  a  patient  who  has  had  symptoms  of  acute 
intestinal  obstruction  for  several  days,  operation  is  contra- 
indicated.  Initial  collapse  is  not  against  operation,  and  if 
operation  be  not  done  in  such  a  case  it  will  probably  soon 
end  fatally. 

Prognosis.  —  Of  operation.  —  Successful  operation  is 
followed  immediately  by  disappearance  of  the  symptoms, 
cessation  of  vomiting,  passage  of  flatus,  and  complete 
recovery.     The  earlier  the  operation  the  better  the  result. 

Gangrenous  bowel  may  rupture  during  the  operation 
and  acute  septic  peritonit's  be  set  up.  The  same  danger 
attends  resection  of  bowel.  Sometimes  an  artificial  anus 
has  to  be  established,  with  all  its  consequent  inconveniences. 
Operative  shock  must  be  guarded  against. 

Without  operation. — In  the  great  majority  of  cases  left 
without  operation  general  peritonitis  sets  in  and  is  fatal. 
Cases  of  recovery  from  symptoms  of  apparent  strangulation 
are  recorded,  but  are  to  be  regarded  only  as  curiosities. 

3.  Occlusion  (obturation-ileus). 

Clinical  Course. — The  onset  of  acute  obstruction  in 
this  condition  is  usually  preceded  by  the  symptoms  of 
stenosis  described  on  p.  227.  After  such  symptoms  have 
been  present  for  some  time,  total  obstruction  supervenes, 
with  incessant  vomiting,  eventually  faecal,  a  rapid  pulse 
of  low  tension,  and  pains  in  the  abdomen.  Finally  in  such 
a  case  signs  of  peritonitis  appear,  and  the  patient  collapses 
and  dies. 

Diagnosis. — When  there  is  a  history  of  the  symptoms 
of  intestinal  stenosis  the  cause  of  the  acute  obstruction  is 
clear. 

With  regard  to  the  actual  cause  of  obstruction,  earlier 
symptoms  of  intestinal  ulceration  will  point  to  cicatricial 
stricture.  Tubercular  lesions  elsewhere,  and  the  presence 
of  a  mass  in  the  ileocaecal  region,  will  suggest  a  tubercular 
process.  Rectal  or  vaginal  examination  may  reveal  a  pelvic 
tumour,  and  a  history  of  the  passage  of  blood  and  mucus 
by  the  bowel  will  make  one  suspect  a  new  growth. 


DISEASES    OF    THE    INTESTINES.  237 

A  scar  the  result  of  injury  or  suppuration  will  point  to 
the  probability  of  kinking  by  peritoneal  adhesions.  The 
passage  of  blood  and  mucus  by  the  bowel  in  a  young  child, 
associated  with  a  cylindrical  shaped  tumour  in  the  abdomen, 
vomiting,  and  distension,  is  in  favour  of  intussusception. 

A  history  of  gall-stone  colic  will  suggest  that  the  obstruc- 
tion is  due  to  a  calculus  in  the  bowel. 

Rectal  examination  and  the  discovery  of  large,  hard 
faecal  masses  will  differentiate  obstruction  from  faecal 
impaction. 

The  diagnosis  of  the  seat  of  obstruction  is  discussed  in 
the  section  on  intestinal  stenosis. 

From  strangulation  a  diagnosis  is  to  be  made  by  the 
presence  of  forcible  peristaltic  movements  and  hyper- 
trophied  bowel.  In  peritonitis  the  bowel  is  paralyzed  and 
the  abdomen  is  tender  to  pressure,  whereas,  in  obstruction 
from  intestinal  occlusion,  pressure  on  the  abdomen  rather 
relieves  the  pain. 

Exaggerated  intestinal  peristalsis  should  be  sufficient 
to  distinguish  the  condition  from  gall-stone  or  renal  colic. 

INDICATIONS    FOR   OPERATION. 

If  the  clinical  signs  definitely  point  to  obstruction  by 
occlusion,  operation  is  called  for  unconditionally  :  (a)  In 
all  cases  in  which  the  condition  has  developed  progressively, 
with  exaggerated  peristalsis  and  meteorism,  even  if  flatus 
and  faeces  are  occasionally  passed  ;  {b)  In  all  cases  of  acute 
intestinal  obstruction.  When  the  latter  is  apparently  due 
to  an  impacted  gall-stone,  operation  should  be  undertaken 
if  the  serious  symptoms  do  not  clear  up  in  a  few  hours,  or 
if  symptoms  of  moderate  intensity  go  on  increasing  in 
severity. 

When  the  diagnosis  is  intussusception,  operation  becomes 
necessary  when  other  means  have  failed. 

In  doubtful  cases  (colic,  etc.)  operation  is  to  be  recom- 
mended when  the  symptoms  do  not  improve  in  spite  of 
medicine  and  other  non-surgical  measures. 

In  cases  which  have  a  long  history  of  symptoms  of 
stenosis  increasing  in  severity,  operation  must  not  be 
■delayed  if  the  general  condition  begins  to  decline,  if  the 
pulse  previously  normal  becomes  more  rapid  and  feeble, 
if  vomiting  becomes  more    and    more  frequent  and   of  a 


238  INDICATIONS    FOR    OPERATION    IN 

bilious  and  perhaps  slightly  faecal  type,  or,  finally,  if  the 
meteorism  becomes  so  marked  that  some  intestinal  coils 
give  a  metallic  percussion  note.  Increasing  vehemence 
and  frequency  of  the  colic,  and  the  involvement  of  an 
increasing  extent  of  the  bowel  in  the  forcible  peristalsis, 
are  also  signs  which  militate  against  delay.  The  pulse  is 
the  most  important  guide  of  all. 

In  general,  it  may  be  said  that  in  intestinal  obstruction 
a  good  general  condition  and  a  pulse  of  sustained  quality 
alone  justify  delay,  and  that  never  beyond  the  second  day 
of  symptoms. 

According  to  the  condition  of  the  patient  and  the  cause 
of  the  obstruction,  the  surgeon  may  choose  to  either  establish 
an  artificial  anus  (in  the  worst  cases  under  local  anaesthesia), 
or  perform  an  entero-anastomosis  excluding  the  obstruction, 
or  resect  the  bowel. 

Contra-indications. — If  rectal  examination  shows  the 
presence  of  large  masses  of  faeces  in  the  rectum,  and  the 
symptoms  are  compatible  with  obstruction  from  impacted 
faeces,  the  rectum  must  be  cleared  out  and  no  operation 
undertaken  unless  the  symptoms  persist.  In  the  course 
of  a  few  months  I  saw  two  cases  presenting  all  the  symptoms 
of  intestinal  obstruction  from  occlusion,  in  which  complete 
recovery  followed  the  manual  removal  of  enormous  masses 
of  faeces  from  the  rectum.  A  bad  general  condition  hardly 
ever  contra-indicates  operation,  as  in  the  worst  cases  an 
enterostomy  can  be  performed  under  local  anaesthesia. 

Immediate  operation  is  not  advisable  if  the  condition  of 
the  heart  is  still  good  and  the  diagnosis  uncertain,  but  if 
the  symptoms  become  clearer,  and  if  the  pulse  begins  to 
fail,  it  is  necessary  to  intervene  surgically. 

Prognosis.  —  Of  operation. — The  symptoms  subside 
when  the  operation  is  successful,  but  whether  the  success 
is  permanent  or  not  depends  upon  the  cause  of  the  occlusion. 
In  tuberculosis  other  strictures  may  develop ;  in  malignant 
growths  complete  removal  may  be  impossible  ;  in  other 
conditions — kinking  by  adhesions,  intussusception,  and 
simple  stricture — the  relief  is  permanent. 

The  risk  of  operation  varies  very  much  according  to  the 
actual  operation  performed.  A  simple  enterostomy  is 
attended  by  no  more  risk  than  that  of  a  simple  opening  into 
the  peritoneal  cavity;  entero-anastomosis  is  more  dangerous. 


DISEASES    OF    THE    INTESTINES.  239 

particularly  if  it  involves  the  large  bowel.  Resection  of 
bowel  is  attended  by  the  highest  mortality  of  all. 

The  risk  from  shock  depends  upon  the  length  and  extent 
of  the  operation  and  the  amount  of  exposure  of  the  bowel. 
An  extensive  operation  may  be  followed  by  some  paralysis 
of  the  gut.  In  some  cases  damaged  bowel  has  ruptured 
in  the  course  of  operation,  and  fatal  peritonitis  resulted. 
If  the  obstruction  cannot  be  removed,  a  permanent  artificial 
anus  is  necessary.  After  entero-anastomosis  it  is  often 
some  time  before  the  abdominal  pains  completely  disappear, 
so  much  so  that  a  return  of  obstruction  may  be  suspected  ; 
as  a  rule  they  disappear  entirely  later.  Ventral  hernia 
can  usually  be  avoided. 

Without  operation. — Peritonitis  supervenes  sooner  or 
later,  with  or  without  perforation  of  the  gut.  In  a  few 
exceptional  cases  recovery  has  taken  place  without  surgical 
intervention.  According  to  Nothnagel  this  is  most  common 
in  cases  of  intussusception,  of  obstruction  by  gall-stones, 
foreign  bodies,  and  fgecal  masses,  and  in  chronic  obstruction 
suddenly  becoming  acute  ;  less  common  in  volvulus,  and 
internal  incarceration  and  kinking  of  the  bowel. 

LITERATURE. 

Baer.  Volvulus  des  S.  romanum.  Centralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chin,   1903. 

Bergmann.  Diagnose  und  Behandlung  der  Darmocclusion.  Arch, 
f.  Min.  Chir.     Bd.  Ixi. 

Erdmann.  Volvulus  as  a  Cause  of  Intestinal  Obstruction.  Med. 
News,  Dec.  6,  1902. 

Dalla-Rossa.  Contribute  alia  Diagnosi  ed  alia  Cura  dell' 
Occlusione  Intestinale.  Riv.  Veneta  di  Sc.  Med.,  Vol.  xxxvii., 
1902,  pp.  9-12. 

GuELLioT.  Volvulus  du  Gros  Intestin.  Bull.  et.  Mem.  de  la 
Societe  de  Chir.  de  Paris.     T.  xxv. 

KocHER.  Ueber  Ileus.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
Bd.  i. 

LiTTLEWOOD.     Seven  Cases  of  Volvulus.    Lancet.     Feb.  18,  1899. 

Naunyn.  Ueber  Ileus.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u. 
Chir.     Bd.  i. 

Nothnagel.     Darmkrankheiten.     2nd  Ed.     Wien,   1903. 

QuENU.  Du  Role  de  I'Angle  Colique  Grande  dans  les  Occlusions 
Intestinales.  Bullet,  et  Mem.  de  la  Societe  de  Chir.  de  Paris,  No. 
23,  1902. 

RouTiER.  Torsion  du  S.  iliaque.  Bull,  et  Mem.  de  la  Societe  de 
Chirurg.  de  Paris.     T.  xxv. 


240  INDICATIONS    FOR    OPERATION    IN 

PiANTiERi.  Sulla  Cura  Medica  e  Chirurgica  del  Volvulo  Intes- 
tinale.     Corres.  Internationale  di  Medic.  Pratica.     No.   ii,   1902. 

ScHLANGE.  Handbuch  d.  prakt.  Chirurgie.  Mikulicz,  Bergmann 
u.  Bruns.     3rd  Vol.,  2nd.  Ed.,  1903. 

ScHLOFFER.  Ileus  bel  Hysteric.  Beitr.  z.  klin.  Chir.  Bd.  xxiv., 
P-  392. 

INTUSSUSCEPTION. 

Etiology. — Intussusception  is  most  common  in  children 
under  the  age  of  four,  and  particularly  common  in  the 
first  year.  In  infants  it  is  usually  due  to  intestinal 
disturbances,  colic  and  diarrhoea  ;  it  is  also  caused  by 
polypi  and  other  intestinal  new  growths. 

Pathological  Anatomy. — The  invagination  is  solitary 
in  most  instances,  and  descending,  that  is  to  say,  the 
intussusceptum  advances  anal- wards.  Several  anatomical 
types  are  distinguished:  the  ileocsecal,  which  is  the  most 
common,  the  enteric,  the  colic.  In  the  ileocaecal  form 
the  ileocaecal  valve  forms  the  apex  of  the  intussusceptum. 
The  mesenteric  attachments  cause  the  intussusceptum 
to  assume  a  concave  outline,  the  concavity  towards  the 
attachments.  The  mesentery  being  compressed,  the 
circulation  of  the  gut  is  interfered  with,  and  hyperaemia  and 
oedema  of  the  intussusceptum  ollow,  and  haemorrhages  also 
take  place  from  and  into  it.  If  the  circulatory  block  is 
acute,  gangrene  may  follow,  and  the  gangrenous  intussus- 
ceptum may  be  passed.  If  adhesions  give  way  when  an 
intussusceptum  becomes  gangrenous  and  separates,  diffuse 
perforation  peritonitis  results.  In  chronic  intussusception 
the  bowel  above  is  dilated  and  hypertrophied.  Local  peri- 
tonitis is  common  in  the  course  of  chronic  intussusception. 

Clinical  Course. — The  onset  is  usually  sudden  and 
associated  with  very  acute  griping  pains.  There  is  often 
an  initial  attack  of  vomiting,  and  an  evacuation  of  the 
bowels.  The  passage  of  material  by  the  bowel  continues, 
and  the  stools  consist  chiefly,  and  after  a  time  entirely,  of 
mucus  and  blood,  the  child  often  having  marked  tenesmus. 
If  the  condition  runs  an  acute  course,  general  collapse  sets 
in  within  the  first  day,  and  the  vomiting  becomes  faecal.  A 
firm  cylindrical  swelling  can  be  felt  on  abdominal  palpation, 
its  extent  and  position  varying  according  to  the  length  of 
time  that  has  elapsed  since  the  onset. 


DISEASES    OF    THE    INTESTINES.  241 

In  the  cases  where  the  course  is  chronic,  the  symptoms 
are  those  of  intestinal  stenosis,  the  pains  are  not  excessive, 
and  as  a  rule  there  is  no  bloody  diarrhoea.  An  abdominal 
tumour  is  recognizable  in  these  cases  also.  In  some  cases 
the  intussusceptum  has  actually  prolapsed  through  the  anus. 

Diagnosis. — If  the  symptoms  described  are  present — 
sudden  pain,  vomiting,  tenesmus,  blood  and  mucus  in  the 
stools,  no  passage  of  faeces  and  flatus,  distension,  and 
abdominal  tumour — the  diagnosis  of  acute  intussusception 
is  definite.  The  tumour  is  the  most  important  sign  in  the 
diagnosis  of  chronic  intussusception,  which  has  to  be 
diagnosed  from  other  forms  of  subacute  and  chronic 
intestinal  stenosis. 

The  acute  form  is  distinguished  from  other  forms  of 
intestinal  strangulation  by  the  passage  of  blood  and  mucus 
by  the  bowel,  and  from  acute  obstruction  supervening  on 
chronic  stenosis  by  the  history  of  symptoms  of  the  latter. 
In  every  case  the  presence  or  absence  of  the  characteristic 
tumour  is  of  much  aid  in  diagnosis,  although  in  early  cases 
it  may  be  impossible  to  feel  it  without  an  anaesthetic. 

INDICATIONS    FOR    OPERATION. 

If  the  diagnosis  is  clear  and  the  symptoms  are  acute,  and 
medical  treatment  has  proved  useless,  operation  should 
be  undertaken  as  early  as  possible.  It  will  consist  in  either 
disinvagination  or  resection. 

The  more  acute  the  symptoms,  the  earlier  faecal  vomiting 
begins  and  the  heart  begins  to  fail,  the  more  urgent  is  the 
operation,  which  should  be  done  within  twenty-four  hours 
whenever  possible.  A  pulse  which  soon  becomes  very 
rapid  and  loses  tension  is  the  strongest  argument  against 
delay. 

When  the  onset  is  less  acute  and  the  symptoms  chronic 
or  subacute,  then  a  more  lengthy  delay  is  justified,  and 
during  this  time  the  "  bloodless  "  methods  of  reposition 
must  be  tried.  If  these  prove  useless  and  the  symptoms 
persist,  the  abdomen  must  be  opened  and  the  condition 
dealt  with  according  to  the  state  of  affairs  which  is  found 
present.  In  the  chronic  type  of  the  affection,  as  well  as  in 
the  acute,  the  pulse  should  be  watched  and  any  signs  of 
heart  failure  interpreted  as  a  call  for  operation. 

The  age  of  the  child  does  not  influence  the  question  of 

16 


242  INDICATIONS    FOR    OPERATION    IN 

operation;    there  should  be  no  hesitation  in  operating  on 
the  young  infant  when  the  symptoms  call  for  it. 

In  subacute  cases  operation  is  not  entirely  justified,  at 
any  rate  during  the  early  stage  of  the  disease,  and  if 
the  general  condition  is  good,  until  insufflation  or  water 
distension  has  been  tried. 

Prognosis. — Of  operation. — The  earlier  the  operation 
the  greater  is  the  probability  of  successful  manual  reduction, 
which  is  only  possible  so  long  as  no  marked  peritoneal 
adhesions  have  formed.  If  resection  is  necessary  the 
chances  of  success  are  much  lessened,  although  a  consider- 
able number  of  recoveries  are  on  record.  During  the 
course  of  operation  the  bowel  may  tear.  Recovery  by 
operation  is  relatively  uncommon  under  the  age  of  two 
years  ;  the  chief  risk  in  infants  is  shock.  According  to 
Wichmann,  in  children  under  one  year  the  percentage 
recovery  by  operation  is  17 ;  between  the  ages  of  i  and  10, 
28  per  cent  ;  above  the  age  of  10,  about  42  per  cent. 
Return  of  invagination  after  reduction  by  laparotomy  is 
very  rare. 

Without  operation. — Occasionally  the  course  is  ultra- 
acute,  and  death  takes  place  within  twenty-four  hours, 
but  this  is  exceptional.  The  ordinary  acute  case  has  a 
course  of  some  eight  days  as  a  rule  ;  the  mortality  in 
children  is  about  80  per  cent.  In  the  subacute  and  chronic 
cases  the  chances  of  recovery  without  operation  are  better, 
but  not  much.  In  the  acute  cases  death  is  the  result  of 
shock  or  collapse  from  the  acute  obstruction.  In  the 
chronic  cases  peritonitis  is  the  usual  actual  cause  of  fatality. 
Spontaneous  recovery  by  sloughing  of  the  intussusceptum 
is  very  unusual  in  children  in  the  iirst  year,  less  uncommon 
in  older  patients.  Occasionally  spontaneous  disinvagination 
has  taken  place  even  when  the  condition  has  been  present 
for  some  weeks. 

LITERATURE. 

D'Arcy  Power.     Intussusception.     Lancet,  1899,  P-  29. 

Clubbe.  a  Clinical  Lecture  on  the  Diagnosis  and  Treatment 
of  Intussusception.     Brit.  Med.  Jour.     Mar.  23,  1901. 

Barlow.     Intussusception.     Lancet,  Nos.  34  &  36,  1899. 

Rebuschino.  Un  Caso  di  Invaginazzione  Intestinale.  Gaz. 
degli  Ospedali,  No.  18,  1902. 

Chavaillon.  Invagination  Intestinale.  La  Province  Medicale, 
No.  24,  1 90 1. 


DISEASES    OF    THE    INTESTINES.  243 

LuBOFF.  Operative  Behandlung  der  Darmeinschiebungen. 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  Bd.  iii. 

Haasler.  Ueber  Darminvagination.  Arch.  f.  klin.  Chir.  Bd. 
Ixviii.,  Hft.  3. 

MoNOD.     De  r Invagination  Intestinale.     These  de  Paris,  1897. 

Onory.     Invagination  Cohque.     Gaz.   Hebdom.,    1901,  No.  49. 

NoTHNAGEL.  Erkrankungen  des  Darmes.  2nd  Ed.  Wien, 
1903. 

ScHLANGE.  Handbuch  d.  prakt.  Chir.  Mikuhcz,  Bergmann,  u. 
Bruns.     Bd.  iii.     2nd  Ed. 

S.  Weiss.  Intussusceptio  Intestini.  Centralb.  f.  d.  Grenzgebiete 
■d.  Med.  u.  Chir.,  p.  702,  1899. 


INTESTINAL    CANCER. 

Intestinal  cancer  is  much  more  common  in  the  male  than 
in  the  female.  Most  patients  are  between  40  and  60.  The 
disease  is  almost  always  primary. 

Pathological  Anatomy. — Carcinoma  of  the  intestine 
is  usually  solitary,  occasionally  multiple.  In  at  least  half 
the  cases  the  seat  is  the  rectum,  the  large  intestine  coming 
next,  and  the  small  intestine  last.  In  only  5 '6  per  cent 
■of  cases  does  the  disease  occur  in  the  latter.  In  the  large 
intestine  the  caecum  and  the  pelvic  colon  are  the  most 
common  situations,  then  the  hepatic  and  splenic  flexures. 

The  disease  is  usually  a  cylindrical-celled  cancer ;  it 
■extends  around  the  bowel  and  gradually  causes  stenosis, 
with  the  usual  dilatation  and  hypertrophy  of  the  bowel 
above.  Ulceration  is  common,  causing  haemorrhage  and 
discharge  ;  an  ulcer  may  perforate  into  the  abdominal 
■cavity  or  a  neighbouring  organ,  or  the  exterior.  Perforation 
into  a  neighbouring  coil  of  bowel  is  not  unusual. 

Clinical  Course. — There  is  often  a  long  latent  period 
in  cancer  of  the  intestine.  The  usual  sequence  of  symptoms 
is  as  follows  :  irregularity  in  the  action  of  the  bowels, 
diarrhoea,  or  alternating  diarrhoea  and  constipation  with 
intervals  of  regularity  ;  there  is  pain  during  the  constipation 
period ;  later  local  abdominal  fullness  and  distension,  and 
abnormal  peristalsis,  with  rigid  contraction  of  a  certain 
segment  of  bowel ;  when  the  attacks  become  severe,  vomiting 
usually  accompanies  them.  The  stenosis  symptoms  often 
show  marked  variations  in  intensity  from  time  to  time. 
The  stage  at  which  the  tumour  becomes  palpable  depends 
upon  its  anatomical  site  to  a  large  extent.     When  palpable 


244  INDICATIONS    FOR    OPERATION    IN 

it  is  often  very  freely  movable,  has  a  nodular  outline,  and  is 
dull  to  percussion,  and  yet  not  absolutely  dull.  Blood  is 
often  found  in  the  stools  :  it  may  be  in  sufficient  quantity 
to  be  seen  with  the  naked  eye,  or  may  be  only  discoverable 
with  the  microscope.  Tenesmus  is  only  present  when  the 
growth  is  in  the  rectum.  Loss  of  appetite,  pallor,  and 
other  general  symptoms  often  precede  the  local  symptoms. 

In  some  cases  the  onset  of  acute  intestinal  obstruction 
is  the  first  definite  sign  of  intestinal  cancer.  The  higher 
the  cancer  the  more  pronounced  and  violent  as  a  rule  are 
the  stenosis  symptoms.  Ulceration  is  a  more  troublesome 
complication  the  lower  the  growth.  Perforation  may  take 
place  into  neighbouring  organs,  e.g.,  into  the  bladder  in  the 
case  of  growth  in  the  sigmoid  flexure. 

Diagnosis. — If  the  symptoms  which  have  been  already 
described  as  those  of  chronic  intestinal  stenosis  (p.  227)  are 
present,  if  there  is  loss  of  appetite,  loss  of  strength  and 
pallor,  and  if  blood  is  found  in  the  stools,  a  diagnosis  of 
intestinal  neoplasm  is  generally  justifiable,  even  although 
there  is  no  palpable  tumour.  A  cancer  of  the  small  bowel  is 
extremely  mobile,  as  is  also  a  growth  of  the  transverse 
colon,  to  a  less  degree  one  of  the  pelvic  colon,  while  in  other 
situations  it  is  commonly  fixed. 

There  are  many  conditions  which  may  simulate  cancer 
of  the  bowel,  the  most  important  being  tuberculosis  and  the 
tuberculous  ileocaecal  tumour,  chronic  intussusception,  and 
fsecal  impaction.  Tumours  of  other  organs  may  also 
simulate  cancer  of  the  bowel  by  encroaching  on  the  latter, 
e.g.,  tumours  of  the  stomach,  gall-bladder,  kidney,  pancreas, 
and  ovary  ;  in  some  such  cases  a  confident  diagnosis  is 
impossible. 

INDICATIONS    FOR    OPERATION. 

If  there  appears  to  be  a  possibility  of  radically  removing 
a  tumour  of  the  bowel,  operation  is  unconditionally 
indicated.  If  it  is  clear  that  a  radical  operation  is  impossible, 
a  palliative  operation  is  only  indicated  when  there  are 
symptoms  of  marked  stenosis  or  complete  obstruction. 
Radical  operation  consists  in  resection  in  one  or  two  stages. 
If  the  bowel  above  the  stenosis  is  much  altered,  the  two- 
stage  plan  gives  much  the  best  results. 

Palliative     operations     are  :      Complete     or     incomplete 


DISEASES    OF    THE    INTESTINES.  245 

exclusion,  simple  entero-anastomosis,  or  the  simple 
formation  of  an  artificial  anus.  Advanced  marasmus  is 
an  important  contra-indication.  If  there  are  signs  of 
metastases,  or  of  encroachment  on  surroundings,  operation 
will  be  deemed  inadvisable,  particularly  if  symptoms  of 
stenosis  or  other  grave  phenomena  are  absent. 

No  operation  of  a  palliative  nature  should  be  undertaken 
unless  it  is  clear  that  some  definite  relief  can  be  given 
thereby  ;  wide  metastasis,  ascites,  and  other  such  pheno- 
mena contra-indicate  interference  of  all  kinds. 

Prognosis. — Results  of  operation. — The  risk  of  resection 
in  malignant  growths  is  very  high,  particularly  when  the 
operation  is  done  in  one  stage  ;  about  a  third  to  a  half  of 
the  cases  have  succumbed  to  collapse,  peritonitis,  and 
other  operation  complications.  The  operation  in  two 
stages  gives  a  lower  mortality.  The  mortality  of  the 
palliative  operations  is  also  high,  but  varies  considerably 
in  the  hands  of  different  surgeons.  Amongst  the  draw- 
backs which  may  result  is  the  persistence  of  an  artificial 
anus. 

Many  operations  have  been  completely  successful,  with 
entire  and  permanent  relief  to  symptoms  ;  palliative 
operations  often  prolong  life  to  a  marked  extent.  After 
entero-anastomosis  the  patient  may  live  for  many  months, 
the  average  duration  of  life  in  Mikulicz's  cases  being  8^ 
months.  After  colostomy  the  average  duration  of  life  is 
from  10  months  to  if  years,  according  to  different  statistics. 

The  number  of  radically  cured  cases  recorded  in  the 
literature  is  not  large,  and  the  proportion  of  cures  varies 
much  with  the  different  surgeons.  Of  12  patients  operated 
on  by  Mikulicz,  5  were  alive  and  free  from  recurrence  at 
periods  of  from  4  to  9|-  years  after  operation.  Of  12  of 
Korte's  cases  4  were  free  from  recurrence  4  years  after 
operation.  Other  operators  have  published  less  satisfactory 
results. 

Without  operation. — The  actual  cause  of  death  is  not 
always  the  same.  Sometimes  it  is  acute  intestinal  ob- 
struction, sometimes  cachexia,  and  in  other  cases  some 
complication  such  as  perforation,  metastasis,  etc.  The 
disease  is  compatible  with  relatively  long  life.  As  a  general 
rule,  the  nearer  the  growth  is  to  the  anus  the  longer  the 
patient  survives,  the  exception  to  this  being  in  the  case  of 


246  INDICATIONS    FOR    OPERATION    IN 

the  very  malignant  rectal  cancers.  The  actual  duration 
from  first  symptoms  to  death  varies  from  a  few  months 
to  six  years. 

LITERATURE. 

A.  Baer.  Die  nichtentzundlichen  Tumoren  der  Ileocaecalgegend. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1900. 

R.  DE  Bovis.  Le  Cancer  du  Gros  Intestin.  Rev.  de  Chir., 
No.  6,  1900. 

Hemmeter.     Carcinoma.     Diseases    of   the    Intestines.      1901. 

KoRTE.  Erfahrungen  iiber  die  operative  Behandhmg  der 
malignen  Dickdarmgeschwiilste.     A-  ch.  f.  khn.  Chir.     Bd.  Ixi. 

Legene.  Les  Tumeurs  MaUgnes  de  ITntestin  Grele.  These  de 
Paris,  1904. 

V.  Mikulicz  und  Kausch.  Krankheiten  des  Darmes.  Handbuch 
d.  prakt.  Chir.  Mickuhcz,  Bergmann,  u.  Bruns.  Bd.  iii.  2nd  Ed. 
1903. 

Monprofit.  Le  Cancer  du  Gros  Intestin.  Progres  Medical. 
Nov.  30,  1901. 

NoTHNAGEL.     Darmkrankheitcn.     2nd  Ed.      1903. 

Stengel.  Pathology  of  Intestinal  Carcinoma.  Textbook  of 
Pathology.      1899. 


CANCER    OF    THE    RECTUM. 

Cancer  of  the  rectum  is  much  more  common  in  men  than 
in  women.  Two-thirds  of  the  patients  are  over  40  years 
of  age,  but  the  affection  is  not  very  uncommon  in  compara- 
tively young  individuals. 

Pathological  Anatomy. — The  carcinoma  cells  are 
usually  of  the  cylindrical  type,  and  may  be  either  adeno- 
matous or  alveolar  in  arrangement,  the  latter  form  being 
very  malignant.  Some  growths  are  soft  and  "  medullary," 
others  are  hard  and  "  scirrhous  "  ;  colloid  cancer  is  common. 
The  central  part  of  the  growth  usually  breaks  down  early, 
the  growth  advancing  by  its  edges.  Surgeons  distinguish 
the  following  anatomical  types  :  (i)  The  marginal  cancers 
of  the  lower  part  of  the  rectal  ampulla,  often  originating 
on  the  anterior  wall  and  soon  encroaching  on  the  whole 
circumference  of  the  bowel ;  this  is  the  commonest  form. 
(2)  The  high,  fibrous  carcinoma,  which  only  involve  a  short 
length,  and  very  early  extend  right  round  the  gut.  (3) 
Diffuse  infiltrating  carcinoma,  involving  a  great  part  of 
the  rectum. 

In  adenocarcinoma  the  glands  are  involved  in  quite  an 


DISEASES    OF    THE    INTESTINES.  247 

early  stage.  The  neighbouring  organs  are  often  encroached 
upon  as  the  growth  extends.  Metastasis  takes  place 
through  the  blood  stream  as  well  as  through  the  lymphatic 
system. 

Clinical  Course. — The  first  symptoms  are  usually 
those  of  a  catarrh  of  the  rectum,  mucus  in  the  stools, 
tenesmus,  the  passage  of  pus  and  blood,  at  first  in  small 
amounts,  but  soon  more  abundantly.  In  the  advanced 
stages  the  discharge  contains  tissue  fragments  and  is  very 
foul  smelling. 

Stenosis  symptoms  are  hardly  ever  absent,  and  often 
appear  early,  especially  in  the  high  cancers.  The  first 
signs  are  then  fullness  of  the  abdomen,  dull  pains,  and 
alterations  in  the  action  of  the  bowels  (diarrhoea,  or 
alternating  diarrhoea  and  constipation)  ;  later  the  colon 
becomes  distended  and  hypertrophied  above  the  stricture. 

General  symptoms  are  often  delayed  in  appearance  until 
the  growth  has  been  present  for  a  considerable  time,  but 
once  established  they  usually  advance  very  rapidly. 
When  the  growth  ulcerates  there  is  often  some  fever,  loss 
of  appetite,  general  weakness,  and  aneemia  from  the  septic 
absorption. 

When  the  growth  extends  to  other  pelvic  structures 
intense  neuralgic  pains  may  be  caused  by  involvement  of 
the  nerves,  septic  cystitis  by  penetration  to  the  bladder, 
and  fulminating  peritonitis  by  perforation  into  the  peri- 
toneal cavity. 

Diagnosis. — A  growth  accessible  to  the  finger  is  felt  as 
a  hard,  nodular  mass  sharply  separable  from  the  soft 
mucous  membrane.  A  high  cancer  can  sometimes  be 
palpated  with  the  patient  standing  up,  and  since  such  a 
growth  gradually  sinks  in  the.  pelvis,  frequent  rectal 
examination  may  reveal  it  when  a  first  examination  proves 
negative;  this  has  been  my  own  experience  in  several  cases. 
In  these  high  growths  the  ampulla,  which  is  normally 
collapsed,  is  often  widely  dilated.  Generally  speaking, 
the  diagnosis  is  based  on  the  presence  of  the  symptoms 
above  detailed. 

Syphilitic  and  gonorrhoeal  ulcers  of  the  rectum  are  soft 
and  superficial,  and  the  edges  not  infiltrated.  Cicatricial 
strictures  are  not  nodular  and  tumour-like,  the  scar  is 
smooth    and    funnel-shaped.      Digital     examination     will 


248  INDICATIONS    FOR    OPERATION    IN 

distinguish  cancer  from  haemorrhoids,  catarrh,  and  other 
processes  which  cause  tenesmus  and  the  passage  of  blood 
and  mucus. 

INDICATIONS    FOR    OPERATION. 

In  carcinoma  that  can  be  removed,  resection  or  amputa- 
tion of  the  rectum  should  be  done  in  as  early  a  stage  as 
possible,  as  soon  in  fact  as  the  diagnosis  is  made,  and 
whether  the  growth  is  high  up  or  low  down.  The  absence 
of  metastases  is  generally  looked  upon  as  a  condition  for 
this  radical  operation  ;  some  surgeons,  however,  undertake 
it  in  spite  of  metastases  if  the  local  state  is  favourable. 

In  carcinoma  that  cannot  be  removed,  many  authors 
advise  (and  I  agree)  the  establishment  of  an  artificial  anus 
when  the  tenesmus  is  very  pronounced,  when  the  patient 
passes  blood  and  discharge  steadily,  and  when  in  spite  of 
purgatives  and  enemata  there  is  obstinate  constipation 
and  considerable  meteorism,  particularly  if  there  is  some 
fever  and  septic  intoxication.  Some  authorities  (Kraske) 
only  perform  colostomy  when  there  are  threatenings  or 
actual  signs  of  obstruction. 

Contra-indications. — High  cancers  which  are  intimately 
adherent  to  bladder  or  to  bone  are  not  suitable  for  radical 
operation,  and  many  surgeons  take  the  same  view  with 
regard  to  adherent  lower  growths.  The  degree  of  adhesion 
can  only,  however,  be  properly  estimated  under  anaesthesia. 
Definite  metastases  in  liver,  peritoneum,  or  elsewhere  should 
be  looked  upon  as  a  bar  to  radical  operation. 

Advanced  age  is  no  contra-indication.  Some  English 
surgeons  look  upon  operation  under  40  as  useless,  owing 
to  early  recurrence.  In  incurable  cases  colostomy  will 
only  be  withheld  when  there  are  no  obstruction  symptoms, 
no  severe  local  symptoms,  and  no  signs  of  chronic  sepsis. 

Prognosis. — Results  of  operation. — Permanent  cures  are 
not  unusual,  considering  as  such,  patients  who  show  no 
recurrence  after  3  years.  The  percentage  varies  in  different 
statistics,  but  most  surgeons  can  show  more  than  15  per 
cent.  In  Czerny's  99  cases,  13  were  free  from  return  more 
than  4  years,  and  8  more  than  5  years  after  operation. 
Hochenegg  reports  17  per  cent  permanent  recoveries  in 
174  cases.  In  incurable  cases  colostomy  usually  prolongs 
life  considerably  ;    of  43  cases  of  Czerny's,  12  lived  more 


DISEASES    OF    THE    INTESTINES.  249 

than  a  year  and  3  months  and  even  up  to  3|-  years  after 
the  operation,  and  28  hved  from  40  days  to  i-J-  years.  The 
functional  resuUs  after  resection  are  much  better  than 
after  amputation  of  the  rectum  ;  in  many  cases  where  the 
sphincter  has  been  retained  there  has  been  both  permanent 
recovery  and  perfect  continence.  Here  again  the  results 
vary  much  in  the  hands  of  different  surgeons. 

When  the  rectum  is  amputated  and  the  sphincter 
removed  there  is  no  sort  of  continence  durmg  the  first 
months,  but  after  that  there  is  continence  for  formed  faeces 
but  not  for  flatus. 

Colostomy  usually  improves  the  general  condition  very 
much;  the  fever,  meteorism  and  signs  of  sepsis  improve, 
and  the  tenesmus  and  diarrhoea  are  lessened.  Sometimes 
the  patient  even  puts  on  weight,  and  may  be  able  to  go 
about  his  work. 

Risks  of  operation. — The  mortality  of  the  radical  operation 
is  high.  About  i  case  in  5  succumbs.  The  statistics  of 
Kronlein  give  a  mortality  of  ig^  per  cent  in  881  cases, 
those  of  Rave  20  per  cent  in  335  cases. 

The  risks  are  greater  in  the  case  of  high  growths  (28 
per  cent,  Rave).  A  surprising  fact  is  that  the  perineal 
operation  is  less  fatal  in  women  than  men,  the  contrary 
being  the  case  as  regards  the  sacral  operation.  The  causes 
of  death  are  wound  infection,  heart  failure  and  collapse, 
and  pulmonary  complications. 

After  amputation  the  anus  is  often  very  troublesome, 
the  incontinence  very  annoying  to  the  patient.  Some- 
times after  resection  a  stitch  or  two  give  way,  and  a  sacral 
faecal  fistula  forms  and  requires  closure  later. 

The  dangers  of  colostomy  are  small,  yet  Czerny  lost 
3  cases  out  of  43.  As  a  rule  the  artificial  anus  can  be  kept 
under  control. 

Without  operation. — The  average  length  of  life  in  en- 
cephaloid  cancer  is  from  one  to  two  years.  In  the  case 
of  the  scirrhous  growths  patients  have  survived  as  much 
as  5  years.  In  young  subjects  the  disease  usually  runs 
a  rapid  course.  Great  suffering  may  be  caused  by  meta- 
stases in  the  liver,  vertebral  column,  and  other  parts. 

LITERATURE. 

Bergmann.  Radikaloperation  bei  Mastdarmkrebs.  Arch  f. 
klin.  Chir.     Bd.  Ixii.      1900. 


250  INDICATIONS    FOR    OPERATION    IN 

BuTLiN.  Rectal  Cancer.  Operative  Surgery  of  Malignant 
Disease,  2nd  Ed.,  1900,  p.  275. 

Cardal.  Resume  des  Methodes  du  Traitement  du  Cancer  du 
Rectum.     Arch.  Gen.  de  Med.,  1898,  i,  p.  582. 

Chalot.  Methode  Abdomino-perineale.  Bull,  et  Mem.  de  la 
Societe  de  Chirurg.  de  Paris,  xxii,  p.  310. 

Goodwin  Gant.     Diseases  of  the  Rectum. 

HocHENEGG.  Ucber  die  Resultate  der  Operation  des  Carcinoma 
Recti.     Verhandlung  der  Deutschen  Gesellsch.  f.  Chir.,  1900. 

Jeanell.  Cancer  du  Rectum.  Arch.  Provin.  de  Chir.  June, 
1901. 

Kraske.  Erfahrungen  iiber  der  Mastdarmkrebs.  Samml.  klin. 
Vortrage,  1897,  Nos.  183  &  184. 

Kronlein.  Resultate  der  Mastdarmkrebsoperationen.  Verhand- 
lung der  Deutschen  Gesellsch.  f.  Chir,  1900. 

QuENU  et  Hartmann.     Chirurgie  du  Rectum.     Paris,  1899. 

Rotter.  Erkrankungen  des  Mastdarmes.  Bergmann,  Bruns, 
u.  Mikulicz.     Bd   iii.     2nd  Ed.      1903. 

Santelet.  Amputation  Perineale  du  Rectum.  These  de  Paris, 
1904. 

Senn.  Pathology  of  Carcinoma  of  the  Rectum.  Pathology 
and  Treatment  of  Tumours,  p.  336.      1895. 


CONGENITAL    DILATATION    OF    THE    COLON. 

This  affection  is  congenital,  and  more  common  in  boys. 
The  whole  colon  may  be  dilated,  or  only  the  descending 
portion.  The  wall  of  the  dilated  bowel  is  as  a  rule 
thickened,  rarely  thinned  ;  the  mucous  membrane  often 
shows  catarrhal  ulcers. 

Clinical  Course. — The  most  prominent  symptom  is 
constipation,  lasting  for  days  and  even  weeks,  appearing 
in  early  childhood  and  even  in  infants  at  the  breast.  The 
abdomen  is  distended,  and  metallic  resonance  is  present 
over  the  dilated  bowel.  Forcible  peristalsis  is  often  to  be 
made  out,  and  also  elevation  of  the  diaphragm.  The  rectal 
ampulla  is  usually  empty.  It  is  often  possible  to  feel  the 
dilated  thick- walled  bowel  through  the  abdominal  parietes. 

Diagnosis. — If  these  symptoms  are  present,  if  there  is 
no  vomiting,  and  if  it  is  possible  to  empty  the  dilated  bowel 
with  a  tube  passed  per  anum,  if  the  tube  evacuates  large 
quantities  of  gas  and  fsecal  matter,  and  the  dilated  bowel 
at  the  same  time  collapses,  the  diagnosis  is  practically 
certain.  A  case  has  been  reported  where  the  diagnosis 
was  supported  by  an  X-ray  picture  after  the  injection  of 


DISEASES    OF    THE    INTESTINES.  251 

an  emulsion  of  bismuth.  Stenosis  or  invagination  are 
excluded  by  the  possibility  of  evacuating  the  bowel  with 
purgatives  and  the  rectal  tube,  and  by  the  absence  of 
vomiting. 

INDICATIONS    FOR    OPERATION. 

When  treatment  by  purgatives  and  the  rectal  tube 
produces  no  improvement  in  the  condition,  when  the 
distension  of  the  colon  persists  and  peritonitis  or  rupture 
threatens,  then  operation  is  called  for.  Operation  is  only 
indicated  when  the  condition  appears  to  threaten  life  in 
some  way.  The  least  dangerous  plan  is  to  establish  an 
artificial  anus  ;  by  this  means  improvement  but  not  cure 
is  obtained.  Radical  operation  involving  the  resection 
of  the  affected  bowel  is  an  extremely  severe  procedure 
considering  the  usual  age  of  the  patient.  Operation  will 
not  be  done  until  an  attempt  has  been  made  to  relieve 
the  alarming  symptoms  by  other  measures.  In  chronic 
cases  operation  should  not  be  advised  so  long  as  relief  is 
given  by  purgatives  and  the  rectal  tube. 

Prognosis  without  Operation. — Most  children  die 
very  young,  but  sometimes  medical  measures  have  allowed 
the  child  to  be  successfully  reared. 

LITERATURE. 

Beighing.  Megalocolon  Congenitum.  La  Clinica  Medica 
Italiana,  xl.,  Pt.  i. 

Fenwick.  Hypertrophy  and  Dilatation  of  the  Colon.  New 
York  Med.  Jour.,  Sept.  i,  1900. 

Hirschsprung.  Jahrb.  f.  Kinderheilkunde.  Bd.  xxvii ;  and 
Berl.  klin.  Wochens.,  No.  44,  1899. 

JoHANESSEN.  La  Dilatation  du  Gros  Intestin  chez  I'Enfant. 
Rev.  Mensu.  des  Maladies  de  I'Enfance.     Feb.,  1900. 

Otto  Silberberg.  Die  Angeborene  Colonerweiterung.  Cen- 
tralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  No.  23,  1903. 


SUBCUTANEOUS    INJURIES    OF    THE    STOMACH 
AND    INTESTINE. 

The  commonest  accidents  giving  rise  to  injuries  of  the 
stomach  and  bowel  are  kicks  from  horses,  compression  by 
the  wheels  of  vehicles,  or  by  the  fall  of  earth  and  such  like, 
and  falls  on  the  abdomen. 


252  INDICATIONS    FOR    OPERATION    IN 

Pathological  Anatomy. — The  injury  may  produce 
contusion,  bursting,  or  tearing.  Lesions  may  be  perforating 
or  non-perforating.  Rupture  is  most  common  in  the  case 
of  the  jejunum  and  ileum.  The  stomach  injuries  number  only 
one  in  ten  (Petry).  The  typical  seat  of  a  rupture  of  the 
stomach  is  at  the  ksser  curvature  of  the  bowel,  at  the  point 
opposite  to  the  mesenteric  attachment.  In  small  tears, 
the  mucous  membrane  may  completely  prevent  the  escape 
of  contents  ;  large  tears,  however,  gape.  In  contusion, 
there  are  haemorrhages  into  the  intestinal  wall,  particularly 
the  submucosa.  Slight  contusions  may  recover  completely, 
and  even  the  severe  types  may  cicatrize  after  exfoliation 
of  the  necrosed  portions  of  the  mucosa.  In  the  worst 
contusions,  late  perforation  usually  takes  place  by  necrosis 
of  the  whole  thickness  of  the  wall. 

Clinical  Course. — Signs  of  shock  appear  immediately, 
whether  the  lesions  are  perforating  or  not.  The  later 
symptoms  are  very  vague  in  non-perforating  injuries  of 
the  stomach ;  the  usual  are  vomiting,  htematemesis  or 
melgena,  and  pain,  symptoms  in  fact  which  suggest  ulcer. 
Non-perforating  duodenal  injuries  produce  the  same  symp- 
toms except  that  vomiting  of  stomach  contents  and  blood 
is  more  unusual.  Contusions  of  the  small  and  large  bowel 
without  rupture  produce  no  constant  clinical  symptoms, 
at  any  rate  in  the  early  stages.  If  the  injury  produces 
rupture,  the  shock  is  preceded  or  accompanied  by  agonizing 
pain  at  the  point  of  perforation,  the  abdominal  walls  are 
board-like,  the  breathing  is  shallow  and  thoracic,  and  there 
is  probably  vomiting.  Free  fluid  can  soon  be  made  out  in 
the  abdomen,  and  gas  collects  at  the  highest  point.  Especi- 
ally important  is  the  gradual  disappearance  of  the  liver 
dullness.  Later,  aU  the  symptoms  of  septic  perforation- 
peritonitis  develop. 

Diagnosis. — A  non-perforating  contusion  of  the  digestive 
tract  can  only  be  suspected.  It  is  only  when  a  large  mass 
of  necrotic  mucous  membrane  is  vomited  up  or  passed  per 
rectum  that  the  diagnosis  is  clear,  and  this  does  not  take 
place  earlier  than  several  days  after  the  injury. 

Free  gas  in  the  peritoneum  is  a  definite  sign  of  perforating 
injury  ;  apart  from  this  it  should  always  be  suspected 
when  the  abdominal  parietes  persistently  remain  rigid, 
when  the  vomiting  is  frequent  and  bilious,  and  when  there 


DISEASES    OF    THE    INTESTINES.  253 

is  free  fluid  in  the  abdominal  cavity.  Also  in  favour  of 
perforation  are  emphysema  of  the  abdominal  wall  (a  rare 
phenomenon),  metallic  quality  of  the  heart  sounds  (also 
rare),  and  respiratory  sounds  which  can  be  heard  over  the 
abdomen. 

Intra-abdominal  haemorrhage  may  present  the  same 
symptoms  as  rupture  of  the  stomach  or  intestine,  and  gives 
the  signs  of  an  intra-abdominal  extravasation.  It  is 
distinguished,  however,  by  the  phenomena  of  acute  anaemia, 
pallor,  lowness  of  temperature,  small  and  rapid  pulse,  and 
rapid,  shallow  respiration. 

The  liver  dullness  may  be  masked  by  meteorism,  but 
free  gas  is  always  associated  with  free  fluid  in  the  abdominal 
cavity,  which  will  prevent  error  and  distinguish  between 
the  two  conditions. 

INDICATIONS    FOR    OPERATION. 

If  in  a  case  of  injury  there  is  even  a  probability  of 
perforation  of  the  stomach  or  intestine,  operation  is 
indicated  to  find  the  injury  and  close  the  opening.  The 
earlier  the  operation  the  better  the  prospect.  If  there  is 
a  commencing  general  peritonitis,  operation  is  definitely 
called  for,  even  when  two  or  three  days  have  elapsed  since 
the  injury.  If  an  early  operation  has  not  been  performed, 
and  if  the  symptoms  have  remained  localized,  operation 
is  only  indicated  when  there  are  definite  signs  of  circum- 
scribed abscess. 

Contra-indications. — Operation  is  contra-indicated  durmg 
the  initial  shock,  but  not  by  shock  present  some  hours 
later,  as  this  may  be  mainly  due  to  a  commencing  peri- 
tonitis. In  the  case  of  injury  to  a  stomach  known  to  be 
empty  it  is  justifiable  to  wait,  but  to  be  ready  to  operate 
at  the  first  suggestion  of  peritonitis.  If  the  time  of  early 
operation  is  passed,  with  local  peritonitis  but  no  signs 
of  generalized  peritonitis,  it  is  permissible  to  temporize  and 
treat  the  local  condition  as  required. 

Prognosis. — Petry  states  that  of  18  cases  of  rupture  of 
the  stomach  by  injury  operated  on  within  24  hours,  45  per 
cent  recovered ;  of  24  operated  on  later,  only  25  per  cent 
survived.  As  has  been  already  said,  sometimes  a  rupture 
recovers  spontaneously,  and  certainly  contusions  often  do 
so.     But  if  signs  of  peritonitis  develop,  which  is  the  rule 


254  INDICATIONS    FOR    OPERATION    IN 

after  rupture  which  is  not  operated  on,  the  patient  is  usually 
lost. 

LITERATURE. 

V.  Angerer.  Operationen  wegen  Unterleibskontusionen.  Ver- 
handlung  d.  Deutschen  Gesellsch.  f.  Chir.,  1900,  Vol  ii,  p.  475. 

EiCHEL.  Subcutane  Darm-  und  Mesenteriumverletzungen. 
Beitr.  z.  klin.  Chir.     Bd.  xxii,  219. 

Jeannel.  Pathologic  Chirurgicale  du  Duodenum.  Arch.  Prov. 
de  Chir.,  1899,  Vol.  vii,  p.  397. 

V.  Mikulicz-Kausch.  Verletzungen  des  Magcns  und  Darmes. 
Handbuch  d.  prakt.  Chir.  Bcrgmann,  Mikulicz,  u.  Bruns.  Pt.  iii. 
2nd  Ed.      1903. 

Stern.     Traumatische     Erkrankung     der     Magenschleimhaut. 
Deut.  med.  Wochens.,  1899,  p.  621. 


APPENDICITIS. 

Etiology. — Appendicitis  is  more  common  in  the  male 
than  in  the  female  sex;  the  majority  of  cases  occur  between 
the  ages  of  10  and  30.  It  is  apparently  always  due  to 
bacterial  infection,  except  a  few  cases  of  amoebic  infection, 
and  many  different  bacterial  forms  have  been  described 
in  association  with  it.  Adhesions  between  the  appendix 
and  surrounding  structures,  and  consequent  kinking, 
predispose  to  the  affection.  An  attack  of  appendicitis  is 
sometimes  preceded  by  acute  tonsillitis,  or  inflammatory 
affections  of  the  female  sexual  organs,  or  chronic  suppurative 
cholecystitis,  in  such  a  way  as  to  point  to  an  etiological 
relationship  between  the  conditions.  The  formation  of 
faecal  concretions  in  the  appendix  seems  often  to  be  a 
determining  cause  of  inflammatory  attacks  ;  foreign  bodies 
only  rarely  have  a  like  effect. 

Pathological  Anatomy. — In  the  mildest  cases  there 
is  a  catarrhal  inflammation,  with  excessive  secretion,  and 
retention  of  the  latter  by  narrowing  of  the  lumen.  Such 
a  process  may  subside  entirely  by  escape  of  the  secretion, 
and  the  appendix  may  then  return  to  the  normal ;  often, 
however,  some  thickening  of  the  wall  remains,  and  a  greater 
or  less  degree  of  inflammatory  stricture.  If  the  retention 
of  the  secretion  persists,  a  condition  of  hydrops  may  be 
produced,  but  much  more  commonly  the  retained  secretion 
is  purulent,  and  the  condition  is  then  one  of  empyema  of 
the  appendix. 


DISEASES    OF    THE    INTESTINES.  255 

This  catarrhal  type  often  passes  into  another  by  ulceration 
and  perforation  of  the  wall ;  in  some  cases  the  perforation 
may  take  place  at  several  spots,  in  others  the  whole  appendix 
becomes  gangrenous. 

The  peritoneum  is  involved  in  almost  all  attacks  of 
appendicitis  ;  in  the  slighter  forms  there  is  only  slight 
adhesive  inflammation,  with  scanty  exudation ;  in  the  severer 
the  exudate  is  more  abundant  and  often  purulent,  even 
when  there  is  no  perforation  ;  in  this  way  the  appendix 
may  lie  in  the  centre  of  an  abscess.  Such  an  abscess  may 
disappear  by  absorption  after  a  more  or  less  prolonged 
time,  or  rupture  into  a  hollow  organ  (most  frequently  the 
bowel),  or  it  may  be  the  starting-point  of  a  chronic  spreading 
peritonitis,  in  the  course  of  which  numerous  intraperitoneal 
abscesses  of  different  sizes  are  formed.  The  process  extends 
along  certain  defined  routes.  Large  abscesses  are  often 
formed  between  the  bladder  and  rectum,  extending  thence 
over  to  the  left  side  ;  in  other  cases  the  process  extends 
upwards,  and  subphrenic  abscesses  form  which  may  make 
their  way  into  the  pleura  or  the  lung,  or  may  further  extend 
as  an  intra-  or  retroperitoneal  process.  In  such  cases 
all  the  coils  of  bowel  may  be  adherent  to  each  other  and  the 
abdominal  parietes.  Rupture  through  the  parietes  is 
unusual. 

In  other  cases  of  perforative  appendicitis  or  peri-appendi- 
cular  abscess  there  is  an  absence  of  localizing  adhesions, 
and  an  acute  diffuse  and  universal  peritonitis  results.  In 
such  cases  absence  of  an  inflammatory  mass  in  the  right 
iliac  fossa  is  usual. 

The  well-known  "  lump,"  which  is  to  be  found  in  so 
many  cases,  consists  usually  of  oedematous  and  infiltrated 
omentum  attached  to  coils  of  bowel  adherent  to  each  other 
and  to  the  parietal  peritoneum  ;  in  the  centre  of  such 
masses  there  is  often  a  collection  of  pus. 

In  some  cases  venous  thrombosis  occurs  early,  and  may 
extend  widely.  As  the  thrombosis  is  often  infective,  a 
severe  type  of  pyaemia  may  result,  with  the  formation  of 
abscesses  in  distant  organs,  particularly  the  liver. 

Clinical  Course. — Following  the  clinical  description 
of  Nothnagel,  one  may  say  that  appendicitis  is  an  affec- 
tion which  presents  itself  under  the  form  of  attacks  with 
intervals. 


2s6  INDICATIONS    FOR    OPERATION    IN 

An  attack  is  often  preceded  by  definite  prodromal  signs, 
but  the  onset  is  also  often  sudden,  with  pain,  nausea,  and 
vomiting.  Signs  of  peritoneal  irritation  soon  supervene 
as  a  rule,  and  there  is  usually  fever  lasting  from  a  few 
hours  to  several  days.  In  the  right  iliac  region  a  cylindrical- 
shaped  body  can  as  a  rule  be  felt,  tender  to  pressure,  and 
corresponding  to  the  thickened  appendix  adherent  to  its 
surroundings.  After  the  inflammation  subsides,  the  thick- 
ened appendix  often  remains  palpable  for  weeks  ;  in  other 
cases  there  is  only  a  tenderness  to  pressure  in  the  right  iliac 
fossa,  without  any  other  recognizable  abnormality.  After 
a  time  all  the  subjective  and  objective  signs  may  entirely 
disappear,  and  complete  permanent  recovery  may  follow. 

In  many  cases,  however,  indefinite  symptoms  persist, 
such  as  a  sensation  of  fullness  or  pressure,  and  often  some 
irregularity  of  the  bowels,  chiefly  in  the  direction  of  constipa- 
tion. After  such  symptoms  have  persisted  for  a  time,  or 
after  an  interval  of  apparent  well-being,  another  attack 
comes  on  which  may  be  of  a  similar  character  to  the  first, 
or  run  a  much  more  serious  course.  Operations  have  shown 
that  even  after  a  first  attack  such  as  has  been  clescribed, 
thickening,  or  adhesions,  or  kinking  of  the  appendix,  or 
adhesions  between  coils  of  bowel,  may  remain  of  such  a 
character  as  to  be  a  source  of  permanent  trouble  to  the 
patient. 

The  following  case  is  a  typical  example.  A  little  girl 
aged  13,  previously  healthy,  after  a  sore  throat,  developed 
an  appendicitis,  with  vomiting,  slight  fever,  and  tenderness 
and  swelling  of  the  appendix.  The  symptoms  subsided 
on  the  second  day,  except  that  the  appendix  remained 
palpable  and  tender.  A  second  slight  attack  occurred  a 
year  and  a  half  later.  Two  years  later,  after  a  slight  injury, 
a  third  attack  came  on  suddenly,  with  vomiting,  fever, 
and  intense  pain  on  pressure  over  the  appendix.  Operation 
was  done  by  Dr.  Schnitzler  eight  hours  after  the  appearance 
of  the  symptoms.  The  appendix  was  long,  its  wall 
thickened,  and  its  tip  adherent  to  the  omentum  ;  the  apex 
was  kinked  and  globular.  Further  examination  showed 
a  ring  stricture  2  cms.  from  the  tip,  empyema  in  the  terminal 
portion,  and  disappearance  of  the  mucous  membrane  above 
and  below  the  stricture.  The  appendix  was  removed  and 
the  child  recovered. 


DrSEASES    OF     THE    INTESTINES.  257 

Appendicitis  imih  tumour  and  abscess  formation  may 
occur  as  a  return  attack  following  one  of  less  severity,  or 
may  commence  acutely  without  prodromal  symptoms 
in  a  patient  previously  healthy.  At  the  onset  there  are 
usually  vomiting,  intense  abdominal  pain,  rigor,  and  fever, 
and  even  symptoms  of  collapse  (small  pulse,  sweating, 
cyanosis)  are  frequent.  After  one  or  two  days  the  general 
symptoms  improve ;  the  abdominal  tenderness,  which  was 
at  first  diffuse,  becomes  localized  in  the  right  iliac  fossa  ; 
the  general  muscular  rigidity  passes  off  and  becomes 
confined  to  the  region  of  the  appendix.  In  this  region 
there  appears  a  firm,  fixed,  tender,  and  ill-defined  swelling, 
over  which  the  parietes  may  be  slightly  fixed  and  oedematous. 
For  the  next  three  or  four  days  the  swelling  either  remains 
about  the  same  size  or  may  become  more  extensive,  in 
which  case  suppuration  will  have  taken  place.  It  is  rarely 
possible  to  make  out  fluctuation.  When  abscess  forms, 
the  pulse  rate  as  a  rule  remains  high  ;  the  observation 
of  the  temperature  is  of  special  importance.  If  fever 
persists  beyond  the  fifth  day  there  is  almost  certainly 
suppuration  ;  rises  of  temperature  with  apyrexic  intervals 
also  indicate  abscess  in  the  absence  of  some  lesion  in  some 
other  organ  to  account  for  it.  It  is  true,  however,  that 
even  in  the  presence  of  extensive  suppuration  the  fever 
may  gradually  subside.  The  position  of  the  swelling 
varies  with  the  position  of  the  appendix ;  sometimes  it  is 
lateral,  sometimes  near  the  middle  line,  and  in  atypical 
cases  it  may  be  in  the  lumbar  region,  or  in  the  pouch  of 
Douglas. 

Appendicitis  with  diffuse  peritonitis  and  no  tumour  is 
usually  rapidly  fatal,  with  symptoms  of  marked  collapse, 
intense  abdominal  pain,  cyanosis,  frequent  vomiting,  a 
rapid  pulse  of  low  tension,  and  subnormal  temperature. 
In  such  cases  the  lesion  is  usually  a  large  acute  perforation, 
or  gangrene  of  the  whole  appendix,  or  rupture  of  an  already 
existing  septic  peri-appendicular  abscess  into  the  general 
peritoneal  cavity. 

In  some  cases  the  peritonitis  runs  an  irregularly  progressive 
course,  with  fibrino-purulent  exudation.  The  temperature 
may  then  show  marked  irregularities  ;  the  tenderness  and 
resistance  which  were  at  first  only  present  in  the  right  iliac 
fossa  extend  gradually  over  the  greater  part  of  the  abdomen. 

17 


258  INDICATIONS    FOR    OPERATION    IN 

Free  fluid  is  not  present  in  the  peritoneal  cavity,  but 
collections  of  pus  may  be  found  on  rectal  or  vaginal  examina- 
tion, or  the  diaphragm  may  be  found  pushed  upwards  by 
a  subphrenic  abscess. 

Rupture  of  an  abscess  into  a  hollow  organ  is  not  uncom- 
mon, but  is  less  so  in  these  days  of  early  operation  than  it 
used  to  be. 

Repeated  rigors,  followed  by  profuse  sweating,  when 
no  tumour  is  present  but  there  is  tenderness  on  pressure, 
point  to  the  onset  of  pylephlebitis.  There  is  often  a  kind 
of  correlation  between  appendicitis  and  inflammatory 
processes  of  the  female  sexual  organs,  in  the  sense  that 
the  one  leads  to  an  attack  or  a  relapse  of  the  other,  and 
vice  versa. 

Diagnosis. — The  presence  of  pain  in  the  right  iliac 
region,  associated  with  a  palpable  and  tender  appendix, 
is  diagnostic  of  appendicitis.  Diffuse  resistance  in  this 
region,  with  or  without  signs  of  peritoneal  irritation,  also 
points  to  appendicitis.  When  a  patient  is  taken  ill  with 
fever,  initial  vomiting,  and  signs  of  peritonitis  or  septicaemia, 
the  discovery  of  tenderness  over  the  appendix  region  often 
settles  the  diagnosis.  According  to  Murphy  the  following 
category  of  symptoms  is  so  typical  that  any  departure  from 
it  must  make  the  diagnosis  uncertain :  (i)  An  attack 
of  abdominal  pain  ;  (2)  Nausea  or  vomiting  from  three 
to  four  hours  afterwards  ;  (3)  General  abdominal  tenderness, 
but  particularly  on  the  right  side  ;  (4)  Rise  of  temperature 
from  two  to  twenty  hours  after  the  onset,  never  before  the 
commencement  of  the  pain. 

In  many  cases  an  exact  diagnosis  of  the  type  of  the 
disease  present  cannot  be  made  even  by  the  most  experienced 
clinicians. 

The  following  symptoms  point  to  the  occurrence  of 
suppuration,  a  matter  of  great  practical  importance  : 
sustained  fever  for  at  least  five  days,  persistent  rapidity 
of  pulse  rate  or  gradual  increase  of  the  same,  persistence 
or  development  of  a  tender  swelling  during  the  first  five  days. 

Much  has  been  written  on  the  subject  of  leucocytosis. 
It  is  generally  agreed  that  if  at  a  single  observation  a  leuco- 
cytosis of  20,000  to  25,000  or  over  is  found,  an  abscess  is 
probably  present,  if  no  other  cause  for  the  leucocytosis 
can  be  found.     Absence  of  leucocytosis  on  the  other  hand 


DISEASES    OF    THE    INTESTINES.  259 

is  not  to  be  looked  upon  as  evidence  against  suppuration. 
A  gradual  increase  in  the  number  of  leucocytes  during  the 
first  few  days  of  the  disease,  up  to  20,000  or  over,  and  a 
maintenance  of  this  increase  is  strong  evidence  of  abscess, 
but  leucocytosis  will  never  be  relied  upon  alone  for  the 
diagnosis.  Such  observations  have  not  hitherto  proved 
of  any  value  in  differentiating  between  circumscribed 
abscess  and  diffuse  spreading  peritonitis. 

The  so-called  iodine  reaction  of  the  blood,  that  is  to  say, 
the  brown  staining  of  certain  granules  in  the  leucocytes, 
supports  the  diagnosis  of  suppuration  when  it  is  present 
in  a  marked  degree. 

It  has  been  recommended  that  exploratory  puncture 
should  be  utilized  to  discover  the  presence  of  pus,  but 
this  is  a  dangerous  proceeding,  and  is  only  mentioned  to 
be  condemned.  A  fluctuating  swelling  in  the  pelvis  con- 
nected with  a  resistance  in  the  right  iliac  fossa,  or  the 
presence  of  a  subphrenic  affection,  is  conclusive  evidence 
of  suppuration  ;  when  pus  makes  its  way  into  the  pelvis 
there  is  often  pain  on  passing  water  or  distinct  bladder 
tenesmus,  and  the  pains  often  radiate  to  the  right  thigh. 

Thrombosis  of  the  portal  vein  or  its  branches  must  be 
diagnosed  when  fever  of  a  pyaemic  type  develops  and  signs 
of  metastatic  sepsis,  in  association  with  a  tender  swelling, 
or  pain,  or  both,  in  the  appendix  region.  Sometimes  the 
pyaemic  symptoms  are  present  for  a  long  time  before  it 
becomes  clear  that  the  appendix  is  the  primary  cause  of 
the  infection. 

A  boy,  aged  12  years,  whom  I  had  the  opportunity  of 
examining  frequently  with  a  colleague,  had  an  illness 
the  symptoms  of  which  were  vomiting  and  fever  of  a  wholly 
irregular  type.  Each  day  he  had  one  or  two  marked 
rigors.  In  the  first  few  days  endocarditis  was  found 
present.  From  the  beginning  there  was  a  strong  suspicion 
that  the  appendix  was  the  cause  of  the  whole  condition, 
but  until  the  third  week  there  was  neither  pain  nor  tender- 
ness in  the  right  iliac  region.  Operation  was  done  the 
first  day  these  signs  made  their  appearance,  and  thrombosis 
of  the  portal  vein  was  found,  the  thrombus  being  partly 
disorganized  and  broken  down.     The  boy  died. 

Gangrene  of  the  appendix  is  to  be  diagnosed  when  there 
are  signs  of  severe  peritoneal  irritation,  intense  localized 


26o  INDICATIONS    FOR    OPERATION    IN 

pain,  and  high  pulse  frequency,  associated  with  absence 
of  an  infiammatory  tumour. 

Acute  perforative  appendicitis  will  be  recognized  by 
the  sudden  onset  of  excessively  acute  pain,  collapse, 
vomiting,  intense  abdominal  rigidity,  rapid  increase  of 
fluid  in  the  peritoneum,  and  rapid  increase  in  the  pulse  rate  ; 
in  some  cases  the  condition  is  distinguished  by  the  disappear- 
ance of  an  already  formed  swelling,  along  with  the  develop- 
ment of  marked  meteorism. 

A  patient,  about  40  years  old,  had  an  attack  of  appendi- 
citis, from  which  he  appeared  to  have  recovered.  Some 
months  later,  when  in  apparent  health,  he  was  suddenly 
attacked  in  the  train  by  vomiting,  excessively  acute 
abdominal  pain,  and  collapse.  Some  hours  later  there  was 
a  subnormal  temperature,  cyanosis  of  the  extremities, 
extreme  tenderness  and  rigidity  of  the  abdomen,  and  signs 
of  fluid  in  the  peritoneum.  Operation  was  performed  by 
Dr.  Schnitzler  five  hours  after  the  onset ;  a  large  perforation 
was  found  in  a  gangrenous  appendix,  and  free  pus  in  the 
peritoneal  cavity.  The  appendix  was  removed,  the 
peritoneum  was  cleansed,  and  the  patient  recovered. 

Rupture  of  an  infective  focus  into  the  general  peritoneal 
cavity  is  to  be  diagnosed  (Dieulafoy)  when  the  pulse  becomes 
suddenly  more  rapid  and  the  meteorism  and  abdominal 
rigidity  increase,  while  the  other  symptoms  simultaneously 
become  less  marked. 

The  diagnosis  of  acute  progressive  purulent  peritonitis 
will  be  made  when  the  abdomen  is  diffusely  tender  and 
distended,  when  the  pulse  becomes  rapid  and  cyanosis 
increases,  when  the  patient  has  a  dry  tongue,  passes  neither 
flatus  nor  fjeces,  and  the  abdomen  contains  free  fluid.  In 
the  later  stage  there  is  a  toxic  euphoria,  coffee  grounds 
vomiting,  a  rapid  and  low  tension  pulse,  cyanosis  of  the 
fingers,  and  great  distension  of  the  abdomen. 

The  subject  of  subphrenic  abscess  complicating  appendi- 
citis is  discussed  in  a  later  chapter.  In  the  early  stages,  when 
the  pus  is  travelling  upwards,  the  thigh  is  usually  flexed 
and  there  is  tenderness  in  the  lumbar  region. 

Chronic  appendicitis,  the  "  appendicitis  larvata "  of 
Ewald,  is  often  mistaken  for  other  affections  :  nervous 
dyspepsia,  gall-stone,  gastric  ulcer,  affections  of  the  bladder, 
etc.     Sometimes  a  thickened  appendix  can  be  made  out 


DISEASES    OF    THE    INTESTINES.  261 

on  palpation,  or  the  only  sign  of  the  disease  may  be  tender- 
ness on  pressure  in  the  right  iliac  region. 

A  young  woman,  23  years  of  age,  had  been  under  treatment 
by  several  physicians  for  ulcer  of  the  stomach,  without 
relief  to  her  symptoms.  She  was  much  depressed,  had  no 
appetite,  and  complained  of  various  nervous  disorders. 
The  appendix  was  thickened  and  tender  to  pressure,  and 
operation  showed  a  chronic  inflammatory  condition.  After 
the  removal  of  the  appendix  the  patient  lost  all  her  gastric 
symptoms,  and  remains  well  two  years  after  the  operation. 

An  officer  complained  of  attacks  of  violent  abdominal 
pain,  which  had  been  variously  interpreted,  mostly  as 
stone  in  the  kidney,  in  consequence  of  slight  vesical 
symptoms.  He  had  had  no  fever.  The  appendix  was 
very  tender  to  pressure,  and  the  pains  evoked  by  pressure 
were  of  the  same  character  as  those  which  occurred 
spontaneously.  At  the  operation  the  appendix  was  found 
doubled  up  and  adherent  ;  its  removal  was  followed  by 
complete  disappearance  of  the  marked  neurasthenia  which 
had  developed. 

Differential  diagnosis. — Many  different  affections  are 
liable  to  be  mistaken  for  appendicitis  ;  I  shall  refer  only 
to  the  most  important.  The  history  must  be  relied  upon 
to  differentiate  perforative  appendicitis  from  other  types 
of  perforative  peritonitis.  Attacks  due  to  gall-stone  or 
renal  stone  may  usually  be  distinguished  by  tenderness 
on  pressure  over  the  liver  or  the  kidney,  or  the  onset  of 
jaundice  or  hsematuria,  and  by  attention  to  the  history. 

Examination  of  the  hernial  orifices  will  exclude  incarce- 
rated hernia.  In  colic,  pressure  usually  relieves  the  pain,  and 
there  is  local  meteorism.  Psoas  abscess  is  less  abrupt  in 
its  onset  than  appendicitis,  and  is  associated  with  signs 
of  vertebral  disease ;  hip-joint  disease  is  distinguished 
by  signs  referable  to  the  joint  itself  and  the  absence  of 
tenderness  or  dullness  in  the  right  iliac  region.  In  favour 
of  perinephritis,  and  against  appendicitis,  will  be  the 
presence  of  an  affection  of  the  urogenital  apparatus.  Palpa- 
tion will  distinguish  torsion  of  a  floating  kidney. 

The  gradual  development  of  a  tumour  in  the  ileoccecal 
region,  associated  with  diarrhoea,  signs  of  progressive 
stenosis,  and  of  tuberculosis  elsewhere,  points  to  a  tuber- 
culosis of  the  bowel. 


262  INDICATIONS    FOR    OPERATION    IN 

If  a  mass  in  the  right  ihac  region  is  large,  intensely  hard, 
of  long  standing,  and  infiltrating  towards  the  surface, 
actinomycosis  will  be  suspected.  In  new  growth  there  is 
cachexia,  intestinal  stenosis,  and  hard,  painless,  and  enlarged 
lymphatic  glands.  The  discovery  of  a  tender  palpable 
appendix  will  serve  to  exclude  nervous  dyspepsia,  gastric 
ulcer,  chronic  cholelithiasis,  and  renal  stone.  If,  however, 
tenderness  in  the  right  iliac  region  is  inconstant  and  varies 
much  at  short  intervals  in  a  neurotic  patient,  the  condition 
is  probably  a  neurosis  and  not  chronic  appendicitis. 

In  enteric  fever  the  history  of  the  disease,  the  enlargement 
of  the  spleen,  and  the  rash,  will  usually  serve  for  a  diagnosis, 
but  confusion  between  this  disease  and  appendicitis  often 
arises,  and  I  have  seen  a  patient  with  enteric  fever  operated 
on  for  supposed  appendicitis. 

INDICATIONS  FOR  OPERATION. 

There  is  much  difference  among  authors  as  to  the  indica- 
tions for  operation  in  appendicitis.  I  shall  give  some 
representative  opinions,  and  also  my  own  views  founded 
on  an  extensive  experience. 

The  indications  as  given  by  Nothnagel  are,  in  outline,  as 
follows  : — 

1.  Operation  is  absolutely  indicated  for  appendicular 
abscess,  wherever  situated,  and  as  soon  as  possible. 

2.  In  diffuse  peritonitis,  operation  gives  the  sole  chance 
of  recovery,  and  should  always  be  done  unless  the  patient's 
general  condition  is  so  bad  as  to  contra-indicate  intervention 
of  any  kind.  It  is  especially  urgent  in  acute  perforative 
peritonitis. 

3.  If  symptoms  of  obstruction  arise  in  the  early  or  later 
stages  of  appendicitis,  and  it  is  not  certain  that  the  condition 
is  due  to  peritonitis,  laparotomy  must  be  done  for  their 
relief. 

4.  In  an  attack  of  appendicitis  which  has  already  lasted 
for  12  ^0  36  hours  without  giving  rise  to  signs  of  peritonitis, 
operation  is  absolutely  necessary  only  if  the  process  is 
suspected  to  be  of  a  severe  phlegmonous,  diphtheritic,  or 
gangrenous  type.  Such  types  are  especially  prone  to  occur 
in  association  with  acute  infective  pharyngitis,  and  some- 
times arise  in  epidemic  form.  In  an  acute  appendicitis 
which  does  not  appear  to  be   of  a  malignant   type,  it  is 


DISEASES    OF    THE    INTESTINES.  263 

legitimate   to  temporize,    and   if    everything  goes    well    it 
may  be  possible  to  avoid  operation  altogether. 

5.  When  an  inflammatory  mass  is  present,  the  state  of 
the  pulse,  the  pain,  and  the  progress  of  the  inflammatory 
condition  are  the  guides  to  operation.  If  there  is  a 
temperature  of  39'5°  or  over  on  the  fourth  day,  or  if  a 
temperature  of  39°  is  sustained  up  to  the  sixth  day,  operation 
is  necessary.  It  is  also  necessary  if  there  is  a  recrudescence 
of  fever  lasting  more  than  twenty-four  hours.  "  In  general 
a  high  temperature  is  an  indication  for  operation,  but 
absence  of  high  fever  is  in  no  sense  a  contra-indication." 

My  own  view  is  that  if  fever  even  of  moderate  degree 
persists  beyond  the  fifth  day  it  means  suppuration,  and 
operation  is  required. 

A  rapid  pulse,  and  a  low  tension  pulse  also,  generally 
indicate  the  necessity  for  operation,  and  the  same  is  true 
of  persistent  acute  pain  or  tenderness  to  pressure,  and  of 
increase  in  the  size  of  the  inflammatory  mass  beyond  the 
first  day  or  two. 

6.  In  the  apyrexic  period,  after  the  acute  process  has 
subsided,  operation  is  called  for  {a)  When  certain  troubles 
persist  in  a  pronounced  form,  such  as  pain,  sensations  of 
fullness  and  weight,  irregular  defaecation,  and  menstrual 
disturbances  ;  {b)  On  the  onset  of  a  relapse.  A  single 
attack  of  appendicitis  which  is  followed  by  apparent 
complete  recovery  justifies  operation  for  removal  of  the 
appendix,  but  it  is  not  absolutely  indicated,  because  three- 
quarters  of  the  patients  who  have  a  single  attack  escape 
relapse. 

Many  surgeons  recommend  that  operation  should  always 
be  done  after  an  attack,  and  at  any  rate  after  a  severe 
attack.  This  recommendation  may  be  accepted  without 
hesitation  if  the  patient  lives  in  some  place  where  surgical 
aid  would  not  be  available  in  case  of  a  severe  relapse. 

Repeated  relapses  call  for  operation,  particularly  if  they 
occur  at  short  intervals,  or  if  the  patient  is  unable  to  regulate 
his  diet. 

Rotter  distinguishes  between  acute  circumscribed 
appendicitis  and  diffuse  appendicitis,  i  e.,  appendicitis 
with  diffuse  peritoneal  symptoms.  In  the  former  he 
recommends  that  operation  should  be  done  whenever 
possible   in   the   interval   after  the   attack.     He    considers 


264  INDICATIONS    FOR    OPERATION    IN 

it  necessary  after  a  first  attack  in  young  patients  (up 
to  35)  who  cannot  be  kept  on  a  strict  regime,  and  who 
are  exposed  to  violent  physical  exertion.  In  the  acute 
stage  the  circumscribed  form  requires  operation  when  the 
symptoms  are  severe  and  in  any  way  alarming.  In  the 
diffuse  form  it  is  necessary  to  operate  when  the  vomiting 
and  pain  have  not  subsided  on  the  third  day. 

Many  writers  uphold  the  view  that  all  attacks  of  acute 
appendicitis  call  for  immediate  operation  (Beck,  MacBurney, 
Murphy,  Dieulafoy,  Tufher,  Kirmisson)  ;  others  think  it 
only  necessary  in  the  presence  of  disquieting  symptoms 
(Lennander).  The  following  reasons  for  early  operation 
are  given  by  Bohm  :  (i)  The  impossibility  of  recognizing 
the  exact  pathological  type  at  the  commencement  of  the 
attack  ;  (2)  The  impossibility  of  giving  a  confident  prognosis 
in  the  early  stages  of  any  attack  ;  (3)  The  relatively  small 
risk  of  early  operation  ;  (4)  The  relief  of  the  patient  from 
the  risk  of  complications,  particularly  the  post-operative 
complications,  hernia,  fistula,  etc.  ;  (5)  The  support  of 
statistics. 

After  a  study  of  the  literature  Bohm  reports  a  general 
agreement  in  the  following  respects  on  the  question  of 
operation  in  the  acute  stage  of  the  disease  :  (i)  Operation 
should  be  undertaken  when  either  at  the  commencement 
or  in  the  course  of  an  attack  alarming  symptoms  and 
signs  make  their  appearance,  whether  local  or  general;  (2) 
When  the  symptoms  of  a  typical  acute  attack  do  not  show 
a  definite  tendency  to  improve  during  the  first  day  or  two 
in  a  uniform  manner,  in  spite  of  careful  expectant  treatment  ; 
(3)  When  a  sudden  aggravation  of  symptoms  occurs  and 
does  not  rapidly  subside  in  the  course  of  an  attack  which 
previously   had   been    of   a   benign   type. 

If  appendicitis  occurs  during  pregnancy  many  authors 
recommend  early  operation  in  view  of  the  risk  to  mother 
and  child  if  the  infective  focus  persists. 

Contra-indications. — Nothnagel  and  other  writers  advise 
against  operation  after  a  single  attack,  if  the  patient  remains 
free  from  pain  and  other  subjective  symptoms  and  no 
abnormality  can  be  discovered  on  abdominal  examination. 
With  this  view  I  agree ;  for  as  has  already  been  stated,  in 
about  three-quarters  of  all  cases,  recovery  after  a  single 
attack  is  permanent. 


DISEASES    OF    THE    INTESTINES.  265 

Many  authorities  hold  that  a  patient  who  is  the  subject 
of  severe  septicaemia  and  diffuse  peritonitis  is  not  a  fit 
subj  ect  for  operation  ;  it  is  particularly  advisable  to  abstain 
from  operation  when  a  condition  of  shock  of  several  days' 
duration  co-exists  with  a  state  of  comparative  euphoria. 
Occasionally,  though  very  rarely,  spontaneous  recovery 
occurs  under  such  circumstances. 

Such  a  result  came  under  my  observation  some  years  ago 
in  the  case  of  a  young  man  with  perforative' peritonitis 
following  appendicitis.  He  had  a  dry  tongue,  blue 
extremities,  a  very  small  and  rapid  pulse,  and  subnormal 
temperature  ;  he  was  also  vomiting  constantly,  and  there 
was  free  fluid  in  the  peritoneal  cavity.  The  surgeon  who 
saw  the  case  considered  it  useless  to  operate.  An  explora- 
tory puncture  was  made,  and  foetid  pus  was  withdrawn. 
For  several  days  he  remained  in  a  condition  of  profound 
collapse,  and  then  commenced  to  improve  by  slow  degrees, 
and  at  the  end  of  six  weeks  left  the  hospital  in  good  condition. 

Haenel  expresses  the  view  that  in  diffuse  peritonitis  no 
operation  should  be  done  when  the  intestine  is  completely 
paralyzed,  when,  that  is  to  say,  it  is  impossible  to  set  up 
peristaltic  movements  by  forcible  percussion,  and  when 
none  can  be  heard  on  auscultation. 

Pyaemic  symptoms  with  repeated  rigors  associated  with 
only  slight  local  signs,  and  signs  which  point  to  thrombo- 
phlebitis in  the  radicles  of  the  portal  vein,  are  looked  upon 
by  many  surgeons  as  contra-indications  to  operation  ;  the 
only  effect  of  operation  would  probably  be  to  lessen  the 
small  chance  which  the  patient  has  of  spontaneous  recovery. 

Some  surgeons  place  the  boundaries  of  justifiable  operation 
very  far  afield  ;  Rotter,  for  example,  would  only  refuse 
to  operate  on  moribund  patients  ;  others,  including  Deaver, 
look  upon  the  presence  of  constitutional  disease,  such  as 
advanced  phthisis,  as  a  contra-indication.  Fowler  and 
others  do  not  approve  of  early  operation  when  a  definite 
retrogression  of  all  symptoms  occurs  within  from  24  to  36 
hours  of  the  commencement. 

The  bursting  of  an  abscess  into  the  bowel,  bladder,  or 
other  hollow  organ,  only  contra-indicates  surgical  mter- 
vention  (Sahli  and  Baumgartner)  when  the  local  and  general 
symptoms  are  permanently  improved  thereby. 

Prognosis. — Results  and  risks  of  operation. — Removal  of 


266  INDICATIONS    FOR    OPERATION    IN 

the  appendix  in  the  interval  after  an  attack  is  a  relatively 
slight  operation.  In  150  such  cases  Rotter  lost  one  patient 
only.  The  risks  are  considerably  higher  in  operation 
during  the  acute  stage.  In  Rotter's  cases  the  mortality 
between  the  years  1893-1895  was  7  per  cent,  between  1896 
and  1900  5  per  cent.  These  figures  are  for  the  circum- 
scribed disease  ;  among  the  cases  of  diffuse  peritonitis  due 
to  appendix  disease  the  mortality  in  the  first  period  was 
60  per  cent,  in  the  second  period  34  per  cent. 

Sprengel  has  published  figures  drawn  from  the  experience 
of  several  surgeons.  Of  232  "  interval  "  operations  2  died  ; 
among  284  operations  during  the  attack,  death  occurred 
in  57.  Of  the  latter  cases  47  were  operated  on  within  the 
first  forty-eight  hours,  with  8  fatalities  ;  237  later  than  this, 
with  49  fatalities. 

Temoin  records  179  operations  during  attack,  with  19 
deaths  ;  17  of  these  were  operated  on  after  the  fifth  day 
of  the  attack. 

Mayo  records  160  interval  operations,  without  a  death, 
115  operations  during  attack,  with  6  deaths.  Lucas- 
Champonniere  lost  12  cases  out  of  44,  with  more  or  less 
diffuse  suppuration  in  the  abdomen  ;  out  of  85  other  cases 
he  lost  none. 

Early  radical  operation  is  specially  easy  and  free  from 
risk  only  if  done  within  the  first  twenty-four  to  thirty-six 
hours  from  the  onset  of  the  attack.  By  this  early  inter- 
vention, complications,  such  as  hernia,  fistula,  etc.,  can 
in  the  great  majority  of  instances  be  avoided. 

According  to  Sonnenberg,  embolus  and  other  pulmonary 
affections  occur  relatively  frequently  after  appendix 
operations. 

The  results  of  operation  in  chronic  appendicitis  are  often 
extremely  gratifying.  The  pain  and  other  symptoms 
disappear,  and  I  have  often  observed  spontaneous  regulation 
of  the  bowels  in  patients  who  had  previously  been  much 
troubled  by  constipation.  The  patients  usually  also  put  on 
weight  and  improve  greatly  in  appearance. 

Operation  during  an  attack  often  directly  saves  life. 
"  Every  patient  with  diffuse  septic  peritonitis  who  recovers 
after  operation  owes  his  life  to  the  operation."  In  35  cases 
of  this  kind  Rehn  reports  recovery  in  8. 

Without    operation. — It    is    stated    that    from   two-thirds 


DISEASES    OF    THE    INTESTINES.  267 

to  three-quarters  of  all  cases  of  appendicitis  recover 
permanently  without  operation.  Nevertheless,  the  disease 
is  full  of  surprises,  and  an  apparently  slight  case  must  always 
be  watched  most  carefully.  It  is  an  established  fact  that 
the  prognosis  of  the  course  of  an  attack  cannot  be  definitely 
stated,  especially  in  the  early  stages.  In  a  considerable 
percentage  of  cases  troubles  of  various  kinds  persist  after 
the  attack ;  these  have  already  been  described  under  the 
term  "  chronic  appendicitis."  In  many  cases  there  are 
return  attacks  of  varying  degrees  of  severity,  from  the 
slightest  to  the  most  dangerous. 

In  perforative  appendicitis  with  peri-appendicular  abscess, 
the  abscess  may  subside  to  a  certain  extent  but  never 
completely,  and  is  a  persistent  menace  to  the  patient.  I 
have  often  seen  autopsies  on  patients  dead  from  septicaemia, 
in  which  such  small  abscesses  were  the  cause  of  death. 
Abscesses  often,  however,  run  a  progressive  course,  with 
the  formation  of  fresh  collections  throughout  the  peritoneum. 
The  rarity  of  subphrenic  abscess  now  as  compared  with 
some  years  ago  is  due  to  the  practice  of  early  operation 
in  appendicitis. 

In  other  cases  perforation  leads  to  death  in  a  few  hours 
to  a  few  days  from  septic  peritonitis  or  pylephlebitis. 

The  percentage  of  deaths  among  cases  of  appendicitis 
not  operated  on  has  been  given  somewhat  variously  by 
various  authors  according  to  the  manner  in  which  the  cases 
have  been  grouped.  The  figures  vary  between  6-10  per 
cent  (Renvers)  and  30  per  cent  (Beck).  By  different 
arrangement  of  the  figures  the  surgeons  seem  to  arrive  at 
the  high  percentages,  the  physicians  at  the  low  percentages  ! 
Certainly,  the  proportion  is  at  least  10  per  cent. 

LITERATURE. 

H.  BoHM.  Die  Indikationen  zur  Chirurgischen  Behandlung  der 
Perityphlitis.  Sammelreferat.  Fortschritte  der  Medizin,  p.  734, 
1902. 

Cattaneo.  Occlusione  Intestinale  ed  Appendicite.  La  Clinica 
Moderna,  No.    10,    1901. 

Chauvel.  De  I'Appendicite  dans  rArmee.  Bull,  de  rAcademie 
de  Medecine  de  Paris,  1899. 

DiEULAFoy,  Reclus,  Tillaux,  Delorme,  Lucas-Champonniere, 
Ibidem. 

DiEULAFoy.  Attendre  pour  Operer  I'Appendicite.  La  Presse 
Medicale,  No.  55,   1902. 


268  INDICATIONS    FOR    OPERATION. 

Gali.et.  Quand  et  comment  faut  il  operer  I'Appendicite.  Gaz. 
Hebdom,  No.  79,  1902. 

JuiLLARD.  Leucocytose  dans  I'Appendicite.  Rev.  de  Chir. 
Mai,  Juin,  Aout,  1904. 

Lennander.  Meine  Erfahrungen  iiber  Appendicitis.  Mitteil. 
a.  d.  Grenzgebiete     Bd.  xiii,  H.  3. 

Lenzmann.  Die  entziindlichen  Erkrankungen  des  Darmes  in  der 
Regio  Ileocaecalis.     Berlin:    Hirschwald.      1901. 

LocKWOOD.  Appendicitis,  its  Patholog}^  and  Surgery.  London, 
1901. 

Murphy.  Two  Thousand  Operations  for  Appendicitis.  American 
Journal  of  Medical  Sciences,  Aug..  1904. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.      1903. 

Payr,  Sprengel.  Appendicitis.  Archiv  fiir  klinische  Chirurgie. 
Bd.  Ixviii. 

RiEPPi.  Contributo  alia  Cura  Chirurgica  dell'  Appendicite. 
Rivista  Veneta  di  Scienze  Mediche,  Vol.  xxxiv.,  1901. 

RussEL   CooMBE.     Appendicitis.     Lancet,  June  4,  1904. 

ScHLANGE.  Perityphlitis.  Handbuch  d.  praktischen  Chirurgie, 
herausgegeben  von  Bergmann,  Bruns,  u.  ^Mikulicz.  2nd  Ed.  Bd.  iii. 
Stuttgart,   1903. 

Spencer.  Indications  for  Surgical  Interference  in  Appendicitis. 
Edin.  Med.  Jour.,  August,  1901. 

Sprengel.  Die  Bedeutung  der  Leukocytose  fiir  die  Indikations- 
stellung  bei  Akuter  Appendicitis.  ]\Iiinchener  med.  Wochens., 
No.   37,   1904. 

Treves.     Appendicitis.     Brit.  Z^Ied.  Jour.,  June  28,  1902,  p.  1594. 

TuRKEL.  Die  Bedeutung  der  Leucocytose  fiir  die  Diagnose 
intra-abdominaler  Eiterungen.  Centralb.  f.  d.  Grenzgebiete  d. 
Med.   u.  Chir.,  No.  14,  1904. 

SoNNENBERG.     PcrityphHtis.     4th    Ed.     Leipzig,    1900. 


CHAPTER    XVI. 

Diseases    of    the    Peritoneum. 


2.7. 


Chapter   XVI. 
DISEASES    OF    THE    PERITONEUM. 

ACUTE    CIRCUMSCRIBED    PERITONITIS. 

Etiology. — Inflammatory  processes  of  any  organ  which 
has  a  peritoneal  covering  may  lead  to  a  circumscribed 
peritonitis.  Excluding  appendicitis,  which  has  been 
considered  in  the  last  chapter,  the  commonest  causes  are 
affections  of  the  female  generative  organs  (puerperal  pro- 
cesses, abortion,  gonorrhoea),  and  of  the  gall-bladder ; 
and,  less  frequently,  ulcerative  processes  of  the  stomach 
and  intestine  and  inflammatory  affections  of  the  parenchy- 
matous organs. 

Pathological  Anatomy. — The  peritoneal  inflammation 
may  be  fibrinous,  serous,  purulent,  or  septic;  in  this  circum- 
scribed type  it  remains  limited  by  adhesions  to  the  neighbour- 
hood of  the  primarily  affected  organ,  and  becomes  encap- 
suled.  Under  a  continuance  of  the  irritation  the  amount 
of  exudate  increases  ;  if  the  latter  is  purulent  or  septic  there 
is  a  great  tendency  for  it  to  make  its  way  from  the  primary 
seat  to  other  parts.  Rupture  of  the  exudation  may  occur 
into  the  general  peritoneal  cavity,  the  vagina,  the  bowel,  or 
the  bladder  ;  often  it  is  completely  absorbed.  Sometimes, 
but  rarely,  this  circumscribed  peritonitis  is  complicated 
by  thrombosis  of  mesenteric  veins  and  pylephlebitis. 

Clinical  Course. — At  the  commencement  of  an  attack 
of  peritonitis  of  this  type  there  is  usually  slight  distension 
of  the  whole  abdomen,  diffuse  pain,  vomiting,  and  constipa- 
tion. In  the  course  of  from  one  to  two  days  the  general 
signs  recede  and  the  local  signs  become  more  prominent. 
The  patient  complains  of  pain  in  the  region  of  the  primary 
focus,  and  is  tender  to  pressure  here  ;  about  the  same  day 
a  resistance  is  felt,  which  in  the  course  of  twenty-four  hours 
becomes  sharply  defined,  and  is  due  to  the  exudate  and  to 


272  INDICATIONS    FOR    OPERATION    IN 

adhesions  between  coils  of  bowel  and  thickened  omentum. 
With  the  aid  of  an  enema  the  bowels  can  usually  be  got 
to  act  about  this  time,  the  meteorism  subsides,  and  rigidity 
of  the  abdominal  wall  is  confined  to  the  region  of  the  "  lump." 
In  addition  to  the  local  exudate  some  free  fluid  may  be 
found  in  the  peritoneal  cavity,  but  usually  only  after  the 
peritonitis  has  been  present  several  days.  After  the  first  few 
days  the  general  condition  is  relatively  good  ;  fever  is  often 
absent.  If  fever  persists  the  exudate  is  probably  purulent. 
The  pulse  is  of  good  tension  and  the  rate  either  normal  or 
only  slightly  increased.  If  the  pulse  becomes  steadily 
more  rapid  the  disease  is  probably  extending. 

Diagnosis. — The  symptoms  just  described  will  establish 
the  diagnosis  of  circumscribed  peritonitis.  If  the  history 
is  indefinite,  either  the  appendix,  the  female  sexual  organs, 
or  the  gall-bladder  will  be  first  suspected  as  the  point  of 
origin  of  the  infection.  The  diagnosis  of  acute  appendi- 
citis has  been  discussed  in  the  previous  chapter.  Pelvic 
peritonitis  is  associated  often  with  functional  disturbance 
of  the  female  sexual  organs  (sudden  pronounced  haemor- 
rhage or  onset  after  haemorrhage)  ;  pain  is  also  most  marked 
deep  in  the  pelvis  and  in  the  neighbourhood  of  the  hip,  and 
there  is  frequently  pain  in  micturition  and  defsecation. 
On  vaginal  palpation  a  parametral  swelling  is  found,  which 
may  encroach  on  the  rectum  behind  to  a  marked  extent. 
Abscesses  which  result  from  pelvic  peritonitis  are  usually 
situated  towards  the  bottom  of  the  pelvis,  and  are  bounded 
by  rectum  behind  and  bowel  above  ;  sometimes  they  are 
more  in  front  of  the  uterus,  and  may  then  be  palpable  above 
the  pubis.  The  history  of  the  case  must  be  relied  upon 
to  differentiate  an  extra-uterine  gestation,  which  is  associ- 
ated with  signs  of  internal  haemorrhage. 

Marked  inflammatory  effusion  around  the  gall-bladder, 
particularly  in  cholelithiasis,  may  be  recognized  by  the 
development  of  a  tender  swelling  below  the  edge  of  the 
liver,  usually  not  moving  with  respiration,  and  associated 
with  signs  of  severe  peritoneal  irritation,  which  gradually 
become  limited  to  the  region  of  the  swelling  ;  it  may  be 
possible  to  make  out  that  the  latter  is  of  a  definitely  doughy 
consistency,  or  even  fluctuating.  Differential  diagnosis 
from  cholecystitis  is  not  easy  and  sometimes  impossible, 
but  the  tumour  of  cholecystitis  is  pear-shaped  and  moves 


DISEASES    OF    THE    PERITONEUM.  273 

with  respiration,  and  the  signs  of  peritoneal  irritation  are 
not  so  pronounced. 

INDICATIONS  FOR  OPERATION. 

Acute  circumscribed  peritonitis  requires  operation  when- 
ever a  collection  of  pus  forms.  As  a  rule,  such  a  collection 
is  treated  by  simple  incision,  and  no  attempt  is  made  to 
deal  with  the  affected  organ  directly  until  the  acute  inflam- 
matory condition  has  subsided  ;  precautions  are  also  taken 
against  the  infection  of  the  general  peritoneal  cavity. 

When  can  suppuration  be  diagnosed  with  certainty  ? 
"  Gradual,  sometimes  comparatively  rapid,  increase  in 
size  of  the  inflammatory  swelling,  increase  in  the  local 
tenderness,  alteration  in  the  consistence  of  the  swelling 
from  hard  to  doughy  :  these  signs,  along  with  alterations 
in  the  pulse  and  temperature,  will  lead  to  the  diagnosis. 
Sustained  or  oscillating  fever  is  an  important  indication  of 
abscess  "  (Korte).  When  an  intraperitoneal  abscess  makes 
its  way  into  the  deeper  parts  of  the  abdomen,  bimanual 
examination  often  gives  valuable  information.  A  dull  per- 
cussion note  over  the  resistance  is  in  favour  of  abscess,  but 
a  tympanitic  note  does  not  negative  it,  because  an  intestinal 
coil  may  lie  in  front,  or  the  abscess  may  contain  gas. 

Exploratory  puncture  has  often  been  employed  to  decide 
the  presence  of  pus,  but  to  pass  a  needle  into  an  intra- 
peritoneal abscess  is  a  risky  proceeding,  and  should  at  any 
rate  never  be  done  unless  preparations  are  made  to  open 
the  abscess  immediately  after. 

Blood  examination  is  often  valuable.  A  steadily- 
increasing  leucocytosis,  up  to  twice  or  three  times  the 
normal,  points  to  suppuration.  A  single  observation  also, 
if  it  reveals  a  leucocytosis  of  18,000  or  over,  points  to  the 
same.  Of  less  value  are  observations  on  the  presence  of 
glycogen  in  the  white  corpuscles,  shown  by  the  yellow 
or  brown  staining  of  granules  ;  little  reliance  will  also  be 
placed  on  the  development  of  peptonuria. 

Even  when  an  increase  in  size  of  the  inflammatory 
swelling  cannot  be  definitely  determined,  and  there  are 
no  signs  of  fluctuation,  if  the  temperature  remains  up  or 
continues  to  rise,  and  if  the  pulse  rate  gradually  mounts, 
an  abscess  is  almost  certainly  present,  and  operation  should 
be  recommended. 

18 


274  INDICATIONS    FOR    OPERATION    IN 

Contra-indications. — Operation  is  not  necessary  when 
there  are  no  signs  of  suppuration ;  a  serous  inflammation 
tends  to  recede  spontaneously.  Generally  speaking,  early 
operation  is  contra-indicated.  In  peritonitis  of  this  type, 
adhesions  limit  the  focus,  and  the  later  the  operation  the 
more  securely  is  the  infective  process  shut  off,  but  operation 
should  never  be  delayed  orice  pus  is  diagnosed.  Exploratory 
puncture  is  specially  contra-indicated  if  there  is  a  tympanitic 
note  over  the  swelling. 

If  thrombophlebitis  complicates  the  peritonitis,  operation 
is  usually  inadvisable  if  there  is  no  definite  local  inflam- 
mator}/  swelling  ;  the  general  symptoms  of  thrombophlebitis 
are  marked  peritoneal  irritation,  high  fever,  repeated  rigors, 
and  profuse    weating. 

Prognosis. — Results  of  operation. — In  most  cases  the 
opening  of  the  abscess  is  followed  by  gradual  complete 
recovery.  In  some  instances,  however,  the  inflammatory 
condition  is  recrudescent,  and  secondary  abscesses  form 
in  the  neighbourhood  of  the  first  after  the  latter  has 
been  opened,  necessitating  repetition  of  the  operative 
interference. 

Sometimes  it  is  necessary  to  operate  afresh  later,  and 
remove  the  primary  source  of  the  infection. 

Without  operatioji. — In  a  not  inconsiderable  number  of 
cases,  particularly  in  those  which  have  their  origin  in  the 
female  genital  organs,  a  kind  of  natural  healing  takes  place 
by  encapsulation  and  gradual  absorption  of  the  exudate. 
This  eventuality  may  be  expected  when  the  general 
inflammatory  signs  subside,  the  fever  lessens,  the  pulse 
becomes  normal,  the  local  tenderness  and  resistance 
disappear,  and  no  fluctuation  is  to  be  found. 

In  many  other  cases  the  inflammatory  condition  tends 
to  spread  ;  with  the  development  of  abscess  comes  the  risk 
of  septic  absorption  and  septicfemia.  Pylephlebitis  is 
another  danger ;  and  lastly  there  is  the  risk  of  rupture  of 
the  abscess  into  the  general  peritoneal  cavity,  setting  up  a 
diffuse  peritonitis. 

LITERATURE. 

KORTE.  Peritonitis.  Handbuch  der  praktischen  Chirurgie, 
herausgegeben  von  Bergmann,  Mikulicz,  u.  Bruns.  Bd.  iii.  2nd 
Ed.      1903. 


DISEASES    OF    THE    PERITONEUM.  275 

NoTHNAGEL.  Erkraiikungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     Wien,    1903. 

V.  WiNKEL.  Peritonitis,  von  den  weiblichen  Genitalien  ausge- 
hend.     Jena,   1897. 

Charles  Mansell.  Treatment  of  Acute  Peritonitis.  Medical 
Press,  June  8,  1904. 

GuENiOT.  Traitement  des  Peritonites  Aigues.  Gaz.  des  Hopit., 
No.  93,  1901. 


DIFFUSE    PERITONITIS. 

Etiology. — In  the  great  majority  of  cases  diffuse 
peritonitis  results  from  the  entry  of  pyogenic  bacteria  into 
the  peritoneal  cavity.  The  most  common  source  of  the 
infection  is  the  appendix,  and  then  follow  certain  other 
abdominal  organs — the  female  genital  organs,  the  stomach, 
the  intestinal  tract,  the  gall-bladder,  the  pancreas,  etc. 
The  peritoneum  may  be  suddenly  flooded  with  more  or  less 
infective  material  by  rupture  of  a  hollow  organ.  In  some 
cases  peritonitis  occurs  as  a  metastatic  condition,  and  it 
may  also  develop  after  operation. 

Aseptic  peritonitis  results  from  chemical  or  mechanical 
irritants ;  thus  it  may  follow  rupture  of  a  hydatid  cyst,  or 
effusion  of  blood,  or  injury  to  the  serosa. 

Pathological  Anatomy.  —  Mikulicz  distinguishes  the: 
following  forms  of  peritonitis ;  the  diffuse  septic,  the  pro- 
gressive fibrino-purulent,  and  the  circumscribed  purulent. 
A  fourth  type  is  often  described  under  the  term  septic£emic 
peritonitis. 

The  diffuse  septic  form  occurs  from  sudden  general 
infection  of  the  peritoneum  by,  for  example,  perforation  of 
one  of  the  hollow  organs.  Adhesions  between  intestinal 
coils  are  absent ;  the  exudate  is  thin  and  either  purulent  or 
serous. 

The  progressive  fibrino-purulent  type  occurs  when  the 
inflammatory  condition  progresses  by  stages,  so  that  in 
the  course  of  several  days  the  greater  part  of  the  peritoneum 
becomes  infected  from  a  small  original  focus — the  appendix, 
for  example.  Such  a  mode  of  progression  is  associated 
with  the  formation  of  various  adhesions  between  the 
intestinal  coils  and  other  abdominal  organs. 

The  third  type,  circumscribed  peritonitis,  has  been 
described   in   the  previous  pages. 


276  INDICATIONS    FOR    OPERATION    IN 

SepticcBinic  peritonitis  occurs  from  the  introduction  of 
bacteria  of  very  high  virulence  into  the  peritoneum,  and 
is  most  common  as  a  post-operative  condition  ;  patholo- 
gically, no  changes  are  found  particularly  characteristic 
of  this  excessive^  rapid  form. 

Rauenbusch  distinguishes  the  different  forms  topographi- 
cally, according  as  they  are  supra-omental  or  infra-omental, 
descending  from  above  downwards,  or  ascending  from  below 
upwards. 

The  digestive  tract  is  the  point  of  origin  of  the  disease 
in  the  majority  of  cases,  and  most  frequently  through  the 
medium  of  perforating  ulceration,  or  direct  wounds. 
Neoplasms  and  phlegmonous  and  ulcerative  processes  may 
cause  peritonitis  without  actual  perforation. 

Other  sources  of  infection  are  the  puerperal  and  gonorrheal 
infections  of  the  genital  organs,  cholelithiasis  and  its  sequelae, 
abscesses  of  the  liver,  and  hydatid  cysts  ;  in  rare  cases  the 
point  of  origin  has  been  a  pancreatitis  or  a  splenic  abscess. 

Clinical  Course. — This  type  of  peritonitis  usually  begins 
acutely,  often  with  a  rigor,  and  as  a  rule  the  patient  feels 
extremely  ill.  The  respiration  is  shallow^  and  rapid.  The 
pulse  rate  is  increased,  and  becomes  continuously  and 
markedly  accelerated  with  the  progress  of  the  disease.  The 
temperature  is  often  much  elevated,  particularly  in  cases 
where  the  peritonitis  is  only  part  of  a  general  septic  infec- 
tion, as  for  example  in  puerperal  peritonitis.  Absence  of 
fever  is  not,  however,  evidence  against  peritonitis  ;  even  the 
purulent  types  may  run  an  entirely  apyrexic  course.  In 
these  cases,  it  is  true,  the  rectal  temperature  is  often  consider- 
ably higher  than  the  axillary.  The  patient  is  restless  and 
distressed,  the  expression  anxious,  the  nose  pinched,  and 
the  extremities  cyanosed  ;  he  is  fully  conscious,  but  may 
fall  into  a  stupid  state  later  ;  not  uncommonly  there  is  a 
sense  of  well-being  before  death.  The  voice  is  small  and 
without  resonance,  the  tongue  dry  and  coated  ;  the  urine 
is  scanty  and  concentrated. 

Abdominal  pain  is  often  localized  at  first  to  the  region 
whence  the  disease  starts,  but  in  other  cases  the  patient 
complains  of  general  pain,  or  refers  it  to  the  neighbourhood 
of  the  umbilicus.  As  the  disease  progresses,  the  pain 
becomes  diffuse,  but  it  may  still  be  greatest  at  the  seat  of 
origin.    At  the  first  onset  it  is  very  acute ;  later,  when  exudate 


DISEASES    OF    THE    PERITONEUM.  277 

forms  and  septic  phenomena  develop,  it  often  becomes  less 
violent.  The  amount  and  the  nature  of  the  exudate  vary 
greatly  in  the  different  types  of  the  disease.  Sometimes 
the  amount  is  so  small  as  to  be  hardly  demonstrable  by 
percussion  ;  in  other  cases  fluid  distends  all  the  dependent 
parts  of  the  abdominal  cavity.  In  some  of  the  gravest 
forms,  the  amount  of  the  exudate  and  other  peritoneal 
symptoms  are  insignificant  compared  with  the  general 
phenomena.  Fluctuation,  particularly  in  the  early  stages, 
is  often  extremely  difficult  to  make  out ;  its  demonstration 
is  best  attempted  by  spreading  one  hand  on  the  abdomen 
and  imparting  movements  to  the  fluid  by  tapping  on  the 
middle  finger  with  the  bent  thumb  of  the  other  hand ; 
these  movements  should  then  be  appreciated  by  the  thumb 
which  lies  on  the  abdomen.  If  the  exudate  is  rich  in  fibrin, 
friction  is  sometimes  heard  over  the  liver  or  spleen.  When 
there  is  free  gas  in  the  peritoneum  the  liver  dullness 
diminishes  with  the  patient  in  the  dorsal  position. 

Vomiting  is  rarely  absent,  and  is  often  the  most  distressing 
of  all  the  symptoms.  It  soon  becomes  bilious  ;  in  septic 
peritonitis  it  may  be  of  coffee-ground  character,  and  if  the 
bowel  becomes  paralyzed  it  is,  as  a  rule,  faeculent.  The 
abdomen  is  usually  distended ;  neither  flatus  nor  fseces  are 
passed,  and  purgatives  are  ineffectual  ;  the  septic  types 
alone  are  relatively  often  associated  with  diarrhoea. 

Perforative  peritonitis  often  sets  in  without  warning, 
but  in  many  cases  there  is  a  history  of  previous  symptoms 
referable  to  one  or  other  of  the  abdominal  organs.  The 
onset  is  sudden,  and  the  pain  agonizing  ;  in  the  first  few 
hours  the  patient  is  collapsed,  the  pulse  small  and  rapid, 
the  abdomen  retracted,  and  the  muscles  board-like,  the 
temperature  often  somewhat  subnormal.  After  several  hours 
the  signs  of  peritonitis  appear — fever,  meteorism,  vomiting, 
and  general  tenderness. 

In  perforation  of  a  typhoid  ulcer  the  first  symptoms 
are  usually  violent  pain  and  shock  ;  sometimes  the  patient 
is  very  restless  some  hours  before  the  perforation  ;  in 
other  cases  the  early  symptoms  are  not  acute  and  there  is 
no  abrupt  onset ;  this  was  the  case  in  two  instances  which 
I  have  recently  seen.  The  temperature  may  fall  rapidly 
or  rise  abruptly  with  rigors.  The  other  symptoms  are 
those  common  to  perforative;  peritonitis  generally. 


278  INDICATIONS    FOR    OPERATION    IN 

Circumscribed  purulent  peritonitis  often  begins  with 
general  peritoneal  symptoms,  meteorism,  diffuse  tenderness, 
vomiting,  constipation,  rapid  pulse,  and  peritoneal  effusion. 
After  some  days  the  inflammation  becomes  definitely 
localized  and  the  generalized  symptoms  subside  (see  last 
Section,  p.  271). 

In  progressive  fibrino-purulent  peritonitis  (Mikulicz)  the 
phenomena  are  at  first  fairly  localized,  and  gradually  the 
tenderness  to  pressure  and  the  distension  extend  more  or 
less  throughout  the  abdomen.  When  well  established, 
the  phenomena  are  those  of  a  general  peritonitis.  The 
condition  may  assume  a  chronic  character,  and  in  this  case 
the  pain  and  vomiting  subside,  the  general  symptoms 
improve,  the  collections  of  pus  increase  and  may  penetrate 
into  some  hollow  organ,  and  the  disease  generally  tends  to 
run  a  latent  course  for  a  long  period. 

Diagnosis. — Peritonitis  is  not  difficult  of  recognition 
if  the  characteristic  symptoms  are  borne  in  mind^ — the  pain, 
vomiting,  meteorism,  intestinal  paralysis,  and  exudation. 
Often  in  the  early  stages  it  is  not  -possible  to  decide  whether 
an  attack  will  result  in  a  localized  or  a  diffuse  condition. 

Differential  diagnosis. — Cases  occur  in  which  it  is  very 
difficult  to  exclude  gall-stone  or  renal  colic,  and  both  these 
forms  of  colic  may  be  associated  with  marked  signs  of 
peritoneal  irritation.  The  tenderness  and  pain  are,  however, 
more  or  less  localized  to  the  neighbourhood  of  the  affected 
organ,  and  the  parietes  are  here  more  rigidly  contracted 
than  elsewhere.  A  certain  degree  of  meteorism  may 
accompany  these  forms  of  colic.  Frequent  desire  to 
micturate,  rectal  tenesmus,  blood  in  the  urine,  or  complete 
anuria,  are  in  favour  of  renal  stone  ;  bile  pigment  in  the 
urine,  jaundice,  and  the  presence  of  a  gall-bladder  swelling, 
point  to  gall-stone. 

Uraemia  is  to  be  distinguished  from  peritonitis  by  the 
results  of  the  urine  examination,  by  the  onset  of  loss  of 
consciousness  and  convulsions,  and  by  the  physical 
examination  of  the  abdomen. 

It  is  sometimes  very  difficult  to  make  a  diagnosis  between 
intestinal  obstruction  and  peritonitis.  The  presence  of 
well-marked  peristaltic  movements,  particularly  if  definite 
local  contracture  of  the  bowel  can  be  made  out,  local  and 
not  diffuse  tenderness,  and  the  absence  of  muscular  rigidity 


DISEASES    OF    THE    PERITONEUM.  279 

of  the  abdominal  walls,  point  to  obstruction  rather  than 
peritonitis.  Fever,  free  fluid  in  the  peritoneum,  diffuse 
tenderness,  leucocytosis,  and  very  severe  general  symptoms 
from  the  beginning,  are  in  favour  of  peritonitis.  In 
peritonitis  the  pain  is  continuous,  in  obstruction  it  tends 
to  come  on  in  attacks.  Meteorism,  paralysis  of  the  gut, 
frequent  and  fseculent  vomiting,  are  symptoms  common 
to  both  affections.  The  absence  of  fever  is  not  a  reliable 
guide  alone  ;    peritonitis  may  run  an  apyrexic  course. 

INDICATIONS  FOR  OPERATION. 

In  all  forms  of  perforative  peritonitis  operation  is  urgently 
called  for.  The  initial  shock  which  occurs  must  be  treated, 
and  not  allowed  to  delay  operation  to  any  considerable 
extent. 

The  abdomen  should  be  opened  whenever  possible  within 
the  first  few  hours,  whether  the  diagnosis  is  quite  clear  or 
only  suspected,  whether  the  symptoms  point  to  perforation 
of  the  stomach,  duodenum,  gall-bladder,  or  appendix,  or  can 
be'  traced  to  the  female  generative  organs  or  to  a  typhoid 
ulcer;  or  when,  the  cause  of  the  condition  being  obscure, 
a  patient  previously  in  health  is  suddenly  attacked  with 
pain  in  the  abdomen,  and  collapse,  and  the  abdominal 
parietes  are  found  rigid,  and  free  fluid  and  gas  are  shortly 
afterward  found  present  in  the  peritoneum. 

In  cases  of  diffuse  inflammation  which  begin  without 
the  symptoms  of  perforation,  the  rule  should  be  followed 
to  operate  as  soon  as  the  symptoms  point  to  an  extending 
peritonitis. 

In  the  progressive  fibrino-purulent  type  of  the  disease 
the  abdomen  should  also  be  opened  at  as  early  a  stage  as 
possible,  and  the  purulent  collections  evacuated. 

The  operative  procedure  in  these  conditions  consists  of 
opening  the  abdomen  under  general  anaesthesia  (excep- 
tionally under  local  infiltration  ansesthesia)  and  mechanically 
cleansing  the  affected  peritoneum.  Many  surgeons  irrigate 
with  normal  saline  solution.  A  perforation  must  be  closed 
by  suture  ;  it  is  often  necessary  to  puncture  or  incise 
distended  bowel.  When  paralytic-ileus  develops  in  the 
course  of  typhoid  fever,  recognized  by  a  rapidly-progressive 
meteorism,  it  is  necessary  to  establish  an  artificial  anus 
(Escher). 


28o  INDICATIONS    FOR    OPERATION    IN 

Contra-indications.—li  from  the  commencement  of  the 
illness  the  signs  of  general  intoxication  overshadow  the 
local  signs,  if,  that  is  to  say,  there  is  an  early  onset  of  tachy- 
cardia and  cardiac  failure,  cyanosis,  shallow  respiration, 
and  shock,  whilst  the  amount  of  exudate  is  small,  operation 
will  be  useless,   and  is  therefore  contra-indicated. 

When  the  signs  of  what  seemed  at  first  a  diffuse  peritonitis 
have  become  localized  and  restricted,  operation  should, 
as  a  rule,  be  delayed  until  the  resulting  abscess  can  be 
opened  without  risk  of  contaminating  the  general  peritoneal 
cavity. 

When  peritonitis  occurs  as  a  single  phenomenon  in  the 
course  of  general  puerperal  septicaemia  its  surgical  treatment 
is  inadvisable. 

A  gonorrhoeal  peritonitis  secondary  to  disease  of  the 
female  genital  organs  does  not  call  for  early  operation  ;  it 
should  be  watched  and  treated  on  expectant  principles  ; 
many  cases  recover  spontaneously. 

Prognosis. — Results  and  risks  of  operation. — In  perforative 
peritonitis  laparotomy  often  saves  life  ;  the  perforation  is 
closed  and  further  escape  of  infective  material  thus 
prevented,  or  the  perforated  structure  (appendix)  is  removed 
entirely  ;  much  toxic  exudate  is  also  removed  from  the 
peritoneal  cavity,  and  the  intraperitoneal  pressure  is 
relieved. 

When  operation  for  perforation  is  done  within  12  hours, 
two-thirds  of  the  cases  are  saved,  but  only  one-third  of 
those  operated  on  during  the  second  12  hours.  When 
there  is  a  delay  of  24  hours  over  80  per  cent  die. 

In  typhoid  perforation  from  20-25  P^r  cent  are  saved 
by  operation  ;  of  87  cases  collected  by  Loison,  16  recovered. 
Of  these  16  cases  six  were  operated  on  from  six  to  twelve 
hours  after  perforation,  four  between  the  twelfth  and  the 
twenty-fourth  hour.  The  latest  statistics  are  those  of 
Zesas — 95  recoveries  in  255  cases.  Of  Hartmann's  cases 
75  were  operated  on .  within  the  first  24  hours  with  19 
recoveries,  38  later  than  this  with  6  recoveries.  The  later 
in  the  attack  the  perforation  occurs  the  more  favourable 
is  the  operative  prognosis  ;  in  the  second  and  third  week 
only  14  per  cent  recover,  in  the  fourth  week  37  per  cent,  and 
later  than  this  about  half  the  cases  are  saved. 

In   cases   of  perforation   of  gastric   ulcer   the   results   of 


DISEASES    OF    THE    PERITONEUM.  281 

operation  are  relatively  good  :  about  50  per  cent  recover, 
probably  owing  to  the  fact  that  operation  is  in  most  cases 
resorted  to  early. 

In  diffuse  peritonitis  originating  from  the  appendix,  from 
28  to  36  per  cent  are  rescued  by  operation. 

The  risk  from  operative  shock  is  apparently  great  ; 
vomiting  may  persist  in  spite  of  operation.  Secondary 
collections  of  pus  may  form  throughout  the  abdominal 
cavity  and  require  opening.  Pleurisy  and  pericarditis 
may  supervene  ;  in  one  of  my  cases  bilateral  perforation 
of  the  diaphragm  occurred  eight  days  after  operation  with 
a  fatal  result.  Ventral  herniae  often  occur  when  the 
abdominal  wounds  are  tamponed. 

Without  operation. — When  the  phenomena  of  general 
intoxication  predominate  the  prognosis  is  excessively 
grave.  Cases  of  septiceemic  peritonitis  of  this  type  die 
as  a  rule  after  a  period  varying  from  a  few  hours  to  a  few 
days.  Diffuse  purulent  spreading  peritonitis  nearly  always 
ends  in  death  ;  occasionally  a  case  becomes  chronic  and 
eventually  recovers  ;  the  length  of  time  a  patient  lasts 
varies  very  much  ;  some  die  in  the  course  of  a  few  days, 
some  survive  for  several  months. 

Acute  perforative  peritonitis  is  also  usually  fatal ;  in 
rare  cases  the  condition  localizes  itself  by  adhesions,  and 
the  patient  recovers. 

Aseptic  peritonitis,  caused  by  mechanical  or  chemical 
irritation,  often  ends  in  recovery,  sometimes  after  very 
alarming  early  symptoms. 

LITERATURE. 

NoTHXAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     Wien,  1903. 

KoRTE.  Peritonitis.  Handbuch  der  praktischen  Chirurgie. 
herausgegeben  von  Mikulicz,  Bruns,  u.  Bergmann.  Bd.  iii.  2nd 
Ed.     Stuttgart,   1903. 

TiETZE.  Chirurgische  Behandlung  der  akuten  Peritonitis.  Mit- 
teil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  v. 

Krogius.  Ueber  die  vom  Processus  Vermiformis  ausgehende 
citrige  Peritonitis.     Jena,  1901. 

Cardi.  Per  la  Cure  della  Peritonitc  del  Perforazionc  nel  Tifo. 
La  Clinica  Medica,  No.    17,   1901. 

Le.n'nander.  Beliandlung  des  perforierenden  Magen-  und  Darm- 
geschwijrcs.     Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  iv. 

EsciiKR.      Die  Behandlung  der    akuten  I^erforalionspcritonitis  im 


282  INDICATIONS    FOR    OPERATION    IN 

Typhus  mittels  Laparotomie  und  Ileostomie.  Mitteil.  a.  d.  Grenz- 
gebiete  d.  Med.  u.  Chir.     Bd.  xi,  H.   i. 

CuRSCHMANN.  Der  Unterleibstyplius.  Nothnagel's  spez.  Pathol, 
u.  Therap.     Wien,   1898. 

Manger.  La  Perforation  Typhique  de  ITntestin.  Paris  :  Stein- 
heil.      1900. 

Terrier.  La  Perforation  Typhique.  Soc.  ^ledic.  des  Hopit. 
de  Paris,  Feb.  8,  1901. 

Roper.  When  to  Operate  in  Perforative  Peritonitis.  Lancet. 
April  20,   1 90 1. 

Manger.  Du  Traitement  Chirurgical  de  la  Peritonite.  Rev. 
de  Chir.     Feb.  10,  1901. 

LoisoN.  Peritonite  Suppuree  Diffuse  Consecutive  a  la  Perforation 
Typhoidique.  ibidem. 

Zesas.  Chirurgische  Therapie  der  typhosen  Perforationsperi- 
tonifis.     Wiener   Klinik,   Wien,    1904. 


CHRONIC    EXUDATIVE    PERITONITIS, 

Etiology. — Trauma  is  undoubtedly  one  of  the  causative 
factors  of  this  condition.  Nephritis  and  obstruction  of 
the  portal  circulation  (hepatic  cirrhosis)  appear  also  to 
give  rise  to  it. 

Pathological  Anatomy. — The  exudate  is  sometimes 
free,  sometimes  encapsuled.  After  the  disease  has  been 
present  for  some  time  the  peritoneum  is  thickened,  and 
has  a  pearly-white  appearance  ;  sometimes  it  is  studded 
with  small  fibrous  nodules,  not  tuberculous  (peritonitis 
fibrosa). 

Clinical  Course. — The  disease  usually  begins  insidiously 
with  abdominal  pain  and  distension.  There  is  often  a 
complete  absence  of  fever.  The  exudate  has  the  general 
characters  of  inflammatory  effusion  ;  sometimes  there  is 
oedema  of  the  lower  extremities  and  of  the  abdominal 
wall.  Vomiting,  circulatory  disturbances,  and  other 
symptoms  of  a  general  character  are  usually  absent, 
nor  are  there  recognizable  changes  in  the  abdominal 
organs. 

Diagnosis. — The  diagnosis  of  this  condition  can  only  be 
provisional,  as  it  is  impossible  before  operation  to  exclude 
tubercular  peritonitis.  The  fluid  gives  a  negative  result 
on  inoculation,  and  there  is  no  reaction  to  tuberculin,  but 
these  negative  results  are  not  sufficient  to  enable  one  to 
be  certain  on  the  matter.     For  the  differential  diagnosis 


DISEASES    OF    THE     PERITONEUM.  283 

from  other  conditions  the  section  on  tubercular  peritonitis 
should  be  consulted  (p.  288). 

INDICATIONS  FOR  OPERATION. 

If  this  form  of  peritonitis  is  suspected,  the  abdomen 
should  be  punctured  if  the  ascites  is  marked  and  troublesome, 
or  dangerous  symptoms  have  arisen  ;  such  symptoms  are 
dyspnoea,  tachycardia,  arythmia,  oedema  of  the  legs,  etc. 
The  opening  of  the  abdomen  and  irrigation,  which  has 
been  recommended  by  several  writers,  is  not  a  proceeding 
which  I  approve  in  the  ordinary  case,  as  the  prognosis  is 
in  general  good  and  the  disease  usually  subsides  sponta- 
neously. Laparotomy  is  at  any  rate  contra-indicated  when 
the  exudate  has  commenced  to  diminish. 

Prognosis. — Results  of  operation. — By  m^eans  of  puncture 
the  patient  can  be  tided  over  the  worst  period  of  his 
•disease  while  the  fluid  is  accumulating,  and  in  this  way 
the  operation  may  be  directly  life  saving.  Once  the 
inflammatory  process  has  passed  its  height  the  patient 
is  out  of  danger.  Laparotomy,  with  lavage  of  the 
abdominal  cavity,  shortens  the  period  of  inflammation  and 
produces  a  more  rapid  healing. 

Without  operation. — If  an  expectant  tonic  treatment 
is  persevered  with,  the  exudate  as  a  rule  com.mences  to 
disappear  and  the  pains  to  diminish  in  the  course  of  some 
weeks  or  months,  seldom  sooner.  There  may  be  remissions 
and  exacerbations.  After  the  disease  has  subsided  there 
often  remain  adhesions  and  thickenings  of  the  peritoneal 
covering  of  the  abdominal  organs. 

LITERATURE. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     Wien,  1903. 

KoRTE.  Krankheiten  des  Peritoneums.  Handbuch  de  prakt. 
•Chir,.  V.  Mikulicz,  Bergmann,  u.  Bruns.     2nd  Ed.     Stuttgart,  1903. 

Lenxander.  Chronisch  exudative  Peritonitis.  Nord.  Med. 
Arkiv.,    1900. 


CHRONIC   INDURATIVE   AND   ADHESIVE    PERITONITIS. 

J£tiolo(;y. — This  form  of  j^eritonitis  may  be  caused  by 
bacterial,  chemical,  or  mechanical  irritation.  It  occurs 
with  especial  frequency  as  a  residuum  of  acute  and  subacute 


284  INDICATIONS    FOR    OPERATION    IN 

peritonitis,  also  in  association  with  chronic  inflammatory 
processes  following  affections  of  the  female  genital  organs, 
the  liver  and  gall-bladder,  and  with  ulcerative  processes, 
and  stenoses  of  the  stomach  and  intestine. 

Constipation,  hernia,  abdominal  wounds,  operations, 
intra-abdominal  menstrual  haemorrhages,  are  also  factors 
of  etiological  importance. 

Syphilitic  processes  in  the  liver  and  spleen  may  give  rise 
to   dense  peritoneal  adhesions. 

Pathological  Anatomy. — The  process  may  lead  to 
adhesions  between  the  surfaces  of  organs  or  to  the  formation 
of  bands.  As  a  result  there  may  be  kinking  of  the  hollow 
organs  and  displacements  or  fixation  of  others.  Sometimes 
the  mesenteric  structures  become  shrunken,  particularly 
the  mesentery  of  the  sigmoid  flexure  (an  important  cause 
of  volvulus),  the  csecum,  and  the  lower  part  of  the  ileum. 
Typical  situations  for  the  development  of  adhesions  are 
at  the  point  where  the  descending  colon  passes  into  the 
sigmoid  colon,  and  at  the  hepatic  and  splenic  flexures. 

A  special  form  of  the  disease  is  the  chronic  hyperplastic 
perihepatitis  (Zuckergussleber),  which  results  in  the 
enveloping  of  the  whole  liver  in  a  whitish  membranous 
exudate  ;  it  is  almost  always  associated  with  chronic 
pleurisy  and  pericarditis. 

The  diffuse  form  of  chronic  peritonitis  with  general 
adhesions  between  all  the  abdominal  organs  is  very  rare. 

Clinical  Course. — Extensive  adhesions  often  form 
without  giving  rise  to  any  symptoms,  but  in  other  cases 
even  slight  adhesions  cause  serious  lesions  by  narrowing" 
or  occluding  bowel  or  by  providing  the  mechanism  of  an 
internal  strangulation,  for  example,  by  fixing  the  extremity 
of  the  appendix  or  of  a  Meckel's  diverticulum.  Adhesions  at 
the  flexures  give  rise  to  the  following  symptoms  (Gersuny)  : 
persistent  chronic  constipation,  pains  on  both  sides  of 
the  lower  part  of  the  abdomen,  increase  of  the  pain, 
especially  that  on  the  left  side,  during  defaecation  and 
during  exercise. 

Adhesions  in  the  neighbourhood  of  the  gall-bladder  often 
simulate  chronic  cholelithiasis.  Two  cases  under  my  own 
care  were  operated  on  for  supposed  gall-stone,  all  that  was 
found  being  adhesions  around  the  gall-bladder  fixing  the 
neighbouring  coils  of  bowel.     Separation  of  the  adhesions. 


DISEASES    OF    THE    PERITONEUM.  285 

cured  the  one,  but  in  the  other  the  symptoms  returned 
again  after  a  month's  respite. 

In  other  cases  the  symptoms  resemble  those  of  gastralgia, 
renal  stone,  or  intestinal  colic,  and  often  the  whole  course 
of  events  is  obscure.  Among  the  symptoms,  pain  always 
predominates,  and  it  may  be  aggravated  by  all  the  causes 
which  stimulate  the  functions  of  the  contractile  organs 
and  often  by  simple  changes  in  the  position  of  the  body. 

Diagnosis. — In  many  cases  the  symptoms  are  so 
capricious  that  some  form  of  neurosis  is  suspected.  Some- 
times, however,  diagnosis  is  possible,  for  example,  when  a 
band  can  be  palpated,  or  when,  after  certain  morbid  affec- 
tions, symptoms  come  on  which  are  difficult  to  explain, 
except  on  the  supposition  of  peritoneal  adhesions. 

After  cholelithiasis,  for  example,  if  signs  of  pyloric 
stenosis  appear  they  will  be  ascribed  to  adhesions,  and 
diagnosis  is  also  possible  where  symptoms  of  intestinal 
stenosis  co-exist  with  hernia  or  follow  penetrating  wounds 
of  the  abdomen. 

A  patient  under  my  care  had  an  old  scar  in  the  ileocaecal 
region,  probably  due  to  an  appendicular  abscess.  He  was 
admitted  to  hospital  on  account  of  acute  pains  in  the 
abdomen  coming  on  in  attacks.  A  coil  of  small  bowel 
with  thickened  wall  was  found  present  constantly  at  the 
same  spot.  Diagnosis  :  Adhesion  of  the  coil  to  the  scar 
left  by  the  abscess  and  kinking.  No  operation  could  be 
done.  The  autopsy  revealed  adhesion  by  a  band  between 
a  coil  of  small  bowel  and  the  parietal  peritoneum. 

A  workman,  35  years  of  age,  had  received  a  knife  wound 
of  the  abdomen  ;  this  healed  uneventfully.  He  had  since 
complained  of  pain  over  the  stomach,  especially  after  a 
meal.  Examination  showed  a  small  hernia  of  the  scar  in 
the  linea  alba.  Operation  revealed  an  adhesion  here 
between  the  bowel  and  the  abdominal  wall,  and  the  separa- 
tion of  this  was  followed  by  complete  disappearance  of 
his  symptoms. 

Adhesions  will  always  be  suspected  when  the  patient 
has  suffered  from  some  disease  likely  to  cause  local  peritonitis, 
and  when  he  complains  of  persistent  or  intermittent  pain, 
which  the  original  lesion  cannot  explain,  as,  for  example, 
when  after  an  apparently  healed  gastric  ulcer  the  patient 
complains  of  intense  pain   without  tenderness  to. pressure 


2  86  INDICATIONS    FOR    OPERATION    IN 

particularly  after  a  meal,  and  when  pains  are  present  in  the 
region  of  the  gall-bladder  in  certain  positions  of  the  body 
subsequently  to  an  attack  of  cholelithiasis. 

Since  the  diagnosis  is  hardly  possible  before  operation 
the  differential  diagnosis  need  not  be  discussed. 

INDICATIONS  FOR  OPERATION. 

If  the  clinical  signs  suggest  peritoneal  adhesions,  and 
if  there  are  persistent  or  intermittent  pains,  operation  is 
indicated  when  the  patient  is  depressed  by  his  malady, 
when  his  general  nutrition  is  suffering,  or  when  marked 
neurasthenic  or  hysterical  symptoms  supervene.  Operation 
is  also  called  for  when  the  condition  interferes  with  the 
patient's  working  capacity,  as,  for  example,  when  he  cannot 
assume  certain  attitudes  without  pain. 

The  indication  for  operation  becomes  absolute  when 
signs  of  gastric  or  intestinal  stenosis  suddenly  or  gradually 
supervene,  or  when  there  are  signs  of  obstruction  from 
volvulus,  a  condition  which  is  liable  to  occur  when  the 
mesentery  becomes  shortened  by  cicatricial  contraction. 

Contra-indications. — If  the  symptoms  are  only  slight 
and  occasional,  operation  is  rarely  necessary.  When  there 
is  reason  to  believe  that  the  adhesions  are  very  extensive, 
the  result,  for  example,  of  a  general  peritonitis  which  has 
progressed  slowly  to  recovery,  the  gravity  of  the  necessary 
procedure  will  deter  the  surgeon ;  but  even  under  these 
circumstances,  if  the  indication  is  absolute  and  the  sufferings 
are  unbearable,  operation  must  be  undertaken. 

Prognosis. — Results  and  risks  of  operation. — In  many 
cases  the  results  of  operation  are  to  the  patient  nothing  less 
than  miraculous.  In  some  cases  the  operation  proves  a 
very  simple  matter,  but  in  others  it  is  extremely  complicated. 
The  separation  of  the  adhesions  may  be  very  laborious  and 
attended  by  much  risk  of  damage  to  the  bowel,  some- 
times requiring  more  or  less  extensive  resection.  The  risk 
to  the  patient  will  of  course  vary  greatly  according  to  the 
gravity  of  the  operation.  It  is  usually  impossible  before 
operation  to  estimate  the  risk  in  any  given  case,  and  it  is 
always  wise  to  give  the  patient  and  his  friends  to  understand 
that  the  operation  is  a  serious  one,  and  to  allow  them  to 
share  in  the  decision,  and  gauge  the  necessity  in  comparison 
with   the  severity  of  the  symptoms.     In  every  case  there 


DISEASES    OF    THE    PERITONEUM.  287 

is  the  chance  that  the  adhesions  may  re-form,  and  means 
must  be  taken  by  the  surgeon  to  prevent  this  as  far  as 
possible. 

Without  operation. — Many  patients  with  peritoneal  adhe- 
sions suffer  greatly  for  many  years.  When  the  adhesions 
obstruct  the  lumen  of  the  bowel  the  whole  train  of 
symptoms  characteristic  of  stenosis  supervene,  and  may 
terminate  fatally. 

LITERATURE. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     Wien,    1903. 

KoRTE.  Krankheiten  des  Peritoneums.  Handbuch  der  prakt. 
Chir,  herausgegeben  von  Bruns,  Bergmann,  u.  Mikulicz.  Bd.  ii. 
2nd  Ed.     Stuttgart,  1903. 

Horace  Wethesill.  Chronic  Adhesive  Peritonitis.  Jour.  Amer. 
Med.  Assoc,  No.   10,  1904. 

CouRTOis-SuFFiT.  Maladies  du  Peritoine.  Traite  de  Medecine, 
Publie  par  Charcot,  Bouchard,  Brisseau.     Tome  iii.     Paris,   1892. 

Gersunv.  Ueber  eine  typische  peritoneale  Adhasion.  Archiv 
f.  klin.  Chir.     Bd.  Hx. 

NoAK.  Peritoneale  Verwachsungen  nach  schweren  Bauch-. 
quetschungen.      Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.    Bd.  iv. 

RiEDEL.  Ileus,  bedingt  durch  Schrumpfung  des  Mesenteriums. 
idem.     Bd.  ii. 

Ders.  Ueber  Adhasiventziindungen  in  der  Bauchhohle.  Langen- 
beck's  Archiv.     Bd.  xlvii. 

Ders.     Peritonitis    Chronica,     ibid    Bd.    Ivii. 

ScHATJTA.     Lehrbuch  der  Gynakologie. 

HiRSCHFELD.  Pcritoncale  Adhasionen  durch  Ulcus.  Mitteil. 
a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  vi. 


TUBERCULAR   PERITONITIS. 

Etiology. — Tubercular  disease  of  the  peritoneum  is 
rare  as  a  primary  condition ;  it  is  usually  secondary  to  tuber- 
cular affections  of  the  lungs,  genital  organs,  intestine,  bones, 
joints,  or  lymphatic  glands  ;  it  is  especially  common  in 
children. 

Pathological  Anatomy.— Three  types  of  the  disease 
are  distinguished  (i)  That  with  abundant  free  serous 
exudate  ;  (2)  That  associated  with  the  formation  of 
adhesions  between  the  coils  of  intestine  and  between  these 
and  the  abdominal  parietes,  and  the  development  of  large 
masses  in  tli(;  om('ntiim  and  the  peritoneum,  and  shrinking 


288  INDICATIONS    FOR    OPERATION     IN 

of  the  mesentery  ;    (3)  The  purulent  ulcerative  form  with 
adhesions  between  the  different  foci. 

Clinical  Course. — The  disease  often  begins  insidiously. 
The  first  symptom  is  usually  pain  in  the  abdomen  of  a 
moderate  degree  of  severity.  Exudation  then  usually 
•collects  rapidly.  Fever  may  be  entirely  absent,  but  in 
most  cases  there  is  at  any  rate  an  evening  rise.  Meteorism, 
difficulties  in  micturition,  constipation,  and  vomiting,  are 
symptoms  which  usually  then  supervene.  The  exudate 
is  at  first  free  in  the  peritoneum,  and  tends  later  to  become 
limited  by  adhesions.  xA.t  this  stage,  nodules  are  often 
palpable,  partly  due  to  thickened  omentum,  partly  to 
infected  lymphatic  glands,  and  partly  to  adhesions  between 
the  coils.  Such  swellings  are  specially  common  in  the 
hypogastrium  and  the  right  iliac  region 

The  general  condition  usually  suffers  markedly,  the 
appetite  fails,  and  diarrhoea  is  not  uncommon.  Symptoms 
referable  to  stenosis  or  kinking  of  the  bowel  are  rare. 

Diagnosis. — When  an  intraperitoneal  effusion  is  dis- 
covered in  a  patient  with  tubercular  disease  elsewhere, 
without  the  co-existence  of  any  acute  abdominal  symptoms, 
the  condition  is  probably  tubercular  peritonitis.  A  charac- 
teristic livid  appearance  of  the  parietes  in  the  neighbourhood 
of  the  prominent  umbilicus,  supports  the  diagnosis  If 
there  is  no  tuberculous  disease  elsewhere,  an  inoculation 
experiment  with  the  fluid  withdrawn  by  puncture  will  be 
of  assistance.  The  reaction  to  tuberculin  may  also  be 
tested,  but  the  method  must  be  cautiously  employed. 
The  formation  of  tumour-like  masses  or  bands,  particularly 
in  the  hypogastrium,  associated  with  some  disappearance 
of  or  encysting  of  the  fluid,  will  add  confirmation.  The 
presence  of  peritoneal  friction  points  only  to  the  peritoneal 
nature  of  the  effusion.  The  passage  of  acholic  fatty  stools 
is  somewhat  in  favour  of  the  tubercular  nature  of  a 
peritonitis. 

In  carcinomatous  peritonitis  there  is  no  encysting  of 
the  exudate,  and  the  presence  of  new  growth  in  other 
organs  can  be  demonstrated. 

Hepatic  cirrhosis  is  associated  with  enlargement  of  the 
spleen,  and  is  characterized  b)/  haematemesis  and  free 
diarrhoea,  and  the  pain,  fever,  and  other  symptoms  of 
peritonitis  are  absent. 


DISEASES    OF    THE    PERITONEUM.  289 

The  "  ascites  of  young  girls  "  disappears  after  the  first 
menstruation,  and  leaves  no  tumour-masses  behind. 

INDICATIONS  FOR  OPERATION. 

There  is  a  great  divergence  of  opinion  as  to  the  indications 
for  operation  in  tubercular  peritonitis.  There  is  no  doubt 
that  laparotomy  has  been  immediately  followed  by  clinical 
and  anatomical  recovery  in  many  cases,  and  on  this  ground 
it  has  been  claimed  by  many  writers  that  the  proper  treat- 
ment of  the  disease  is  by  operation.  Some  surgeons  have 
advised  operation  only  in  the  cases  with  free  or  encysted 
exudate ;  others  have  operated  on  all  types,  even  when 
tumour-like  masses   were  present. 

Physicians  have  of  late  years  become  more  and  more 
inclined  to  the  conservative  treatment  of  the  disease  in  all 
its  forms. 

I  consider  operation  called  for  under  the  following 
circumstances  :  (i)  When  the  exudate  is  free,  and  is  present 
in  such  amount  as  to  cause  serious  symptoms  and  endanger 
life  ;  (2)  When  perforation-peritonitis  supervenes,  provided 
that  there  are  no  serious  tuberculous  lesions  in  other  organs  ; 
in  all  my  cases  there  has  been  advanced  disease  in  other 
organs,  and  I  have,  therefore,  never  advised  operation. 
(3)  When,  in  the  serous  or  the  adhesive  forms  of  the  disease, 
internal  and  external  treatment  has  proved  unavailable 
after  several  months'  trial,  and  when  the  other  organs  are 
either  free  from  disease  or  only  slightly  affected. 

The  indications  under  the  two  last  headings  are  not 
absolute.  Practitioners  will  do  well  to  follow  as  a  general 
rule  the  present  trend  of  opinion,  and  incline  towards 
conservative  rather  than  operative  treatment. 

The  operative  procedure  adopted  in  most  cases  has  been 
the  opening  of  the  abdomen,  with  or  without  wiping  over 
or  washing  out  the  cavity.  Other  surgeons  have  injected 
sterilized  air  or  irritating  substances— iodoform,  naphthol- 
camphor,  etc.  The  separation  of  adhesions  has  rarely  been 
undertaken.  Relatively  often  the  abdomen  has  been 
punctured  to  relieve  dangerous  symptoms  caused  by  the 
accumulated  fluid. 

Contra-indications. — The  advocates  of  operation  look 
uprm  advanced  tuberculosis  of  other  organs  as  the  only 
contra-indication  to  operation,  and  do  not  consider  as  such 

19 


290  INDICATIONS    FOR    OPERATION    IN 

the  presence  of  fever  or  tuberculosis  of  other  serous  mem- 
branes. Others,  however,  consider  that  the  form  of  the 
disease  which  is  associated  with  sustained  fever,  particularly 
when  there  are  also  masses  formed  in  the  abdomen,  is 
unsuitable  for  operation,  and  is  unfavourably  influenced 
thereby.  According  to  Borchgrevink,  when  there  is  no 
fever  the  disease  usually  runs  a  favourable  course,  and 
operation  is  not  required. 

Prognosis. — Results  of  operation. — It  is  difficult  to  gauge 
the  value  of  operation  from  the  quoted  statistics,  as  they 
have  been  compiled  from  such  opposite  points  of  view.  It 
is  true  that  many  cases  recover  after  laparotomy,  but  it  has 
been  objected  by  those  who  are  against  operation  that  the 
same  result  might  have  been  obtained  without  opening  the 
abdomen.  All,  however,  who  have  watched  the  course  of 
such  cases  must  admit  that  clinical  and  anatomical  recovery 
often  results  and  is  permanent.  The  percentage  of  recoveries 
given  by  different  writers  varies  between  the  33  per  cent 
of  Frees  and  the  94  per  cent  of  Mazzoni ;  but  the  figures 
for  the  most  part  do  not  deal  with  the  question  of  permanent 
recovery.  Those  given  by  Konig  are  important  in  this^ 
respect :  in  161  operations  there  were  65  per  cent  of  recoveries, 
but  permanent  cure  after  2  years  in  24  per  cent  only. 
Margarucci  also  gives  somewhat  similar  figures,  253  opera- 
tions, 75  per  cent  recoveries,  26  per  cent  permanent  cures. 

Risks  of  operation. — Simple  abdominal  section  for  tuber- 
cular peritonitis  is  relatively  free  from  risk ;  in  very  few 
cases  has  death  occurred  ascribable  to  the  operation. 
Insufflation  is  also  a  harmless  procedure.  The  presence 
of  complications  makes  the  prognosis  graver  ;  within 
one  year  I  lost  three  cases  on  this  account ;  in  one  there 
was  an  intestinal  tuberculosis,  and  in  the  other  two  there 
was  a  complicating  liver  affection.  Puncture  when  the 
fluid  is  free  is  not  dangerous,  but  accidents  may  happen 
when  it  is  encysted  ;  two  cases  of  my  own  succumbed  to 
a  wound  of  the  bowel,  although  in  each  case  the  surgeon 
was  experienced  ;  the  punctured  bowel  was  adherent, 
empty,  and  dull  to  percussion. 

Faecal  fistula  has  developed  relatively  often  after  operation ; 
according  to  Friedlander  this  complication  occurs  in  about 
4  per  cent  of  fatal  cases  which  are  not  operated  on,  while 
among  the  cases  fatal  after  operation  it  is  present  about  a 


DISEASES    OF    THE    PERITONEUM.  291 

quarter  (Borchgrevink)  or  even  a  half  (Korte).  It  must  be 
noted  that  these  figures  refer  to  fatal  cases,  not  to  all  cases 
Without  operation. — Spontaneous  recovery  often  occurs 
after  a  varying  duration  of  time,  even  when  at  one  stage 
or  another  the  symptoms  are  marked  and  alarming, 
and  I  have  seen  many  cases  in  which  this  recovery  was 
permanent.  The  figures  of  A.  Frank  and  Borchgrevink 
appear  to  show  that  spontaneous  cure  is  more  common 
among  the  non-operated  than  among  the  operated  cases. 
Frank  records  cure  in  a  half,  Borchgrevink  in  81  per  cent, 
of  the  first,  while  among  the  operated  cases  the  recoveries 
are  given  by  these  writers  respectively  as  38  per  cent  and 
63  per  cent.  In  regard  to  the  late  history  of  the  unoperated 
cases,  the  figures  given  by  Rose  from  Naunyn's  clinic  are 
interesting  ;  of  56,  two-thirds  died,  one-third,  including 
some  severe  cases,  recovered. 

LITERATURE. 

L.  Teleky.  Die  Bauchfelltuberkulose  und  ihre  Behandlung. 
Zusammenfassendes  Referat.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Chir.      1899. 

G.  Zesas.  Ueber  die  Laparotomie  bei  tuberkuloser  Peritonitis. 
Zusammenfassendes    Referat.     Ebendaselbst.      1903. 

Borchgrevink.  Zur  Kritik  der  Laparotomie  bei  der  Bauchfell- 
tuberkulose.    Mitteil.   a.   d.   Grenzgebiete.     Bd.   vi. 

Frank.  Operative  Behandlung  der  Chronischen  Bauchfelltuber- 
kulose.    Ibidem. 

Rose.  Ueber  den  Verlauf  und  die  Heilbarkeit  der  Bauchfell- 
tuberkulose.     Ibid.      Bd.   viii. 

Herzfeld.  Zur  Chirurgischen  Behandlung  der  tuberkulosen 
Bauchfellentziindung.     Ibid.     Bd.  v. 

Nothnagel.  Erlsrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     Wien,  1903. 

Terrier.  Peritonite  Tuberculeuse  Chronique.  La  Presse 
Medicale,  8  annee,  No.  71. 

Banteignie.  De  1' Occlusion  Intestinale  dans  la  Peritonite  Tuber- 
culeuse.    These  de  Paris.      1902. 

Mainot.  Traitement  des  Peritonites  Tuberculeuses  par  les 
Lavages  d'Eau  Sterilisee.     These  de  Paris,  1901. 

Lejars  et  QuENU.  LTntervention  Chirurgicale  dans  la  Peri- 
tonite Tuberculeuse.  Bullet,  et  Memoires  de  la  Societe  de  Chirurgie 
de  Paris.     Tome  xxiv.,  Nos.  22,  34,  35. 

Fenger.     Treatment  of  Tuberculosis.     Annals  of  Surgery,   1901. 

Schwarz.  Cura  della  Peritonite  Tuberculosa.  Riv.  Veneta 
di  Scienzc  Mediche.     Tome  xxxvii.,  No.  4. 

Macart.vey.  Laparotomy  in  Tubercular  Peritonitis.  Glasgow 
Med.  Jour.,  August,  1901. 


CHAPTER     XVII. 

Diseases    of    the    Peritoneum 

[continued). 


295 


Chapter    XVII. 
DISEASES    OF    THE    PERITONEUM  (contd.). 

TUMOURS    OF    THE     PERITONEUM,     OMENTUM,     AND 
MESENTERY. 

Etiology. — Cystic  tumours  may  make  their  appearance 
at  any  age  ;  diffuse  new  growths  of  the  peritoneum  are 
most  common  in  advanced  age. 

Pathological  Anatomy. — The  malignant  growths  are 
usually  metastatic,  secondary  in  particular  to  cancer  of 
the  uterus,  stomach,  bowel,  pancreas,  or  gall-bladder. 
Diffuse  sarcomatous  growths  (sarcomatosis  peritonei)  are 
comparatively  very  rare.  Both  carcinoma  and  sarcoma 
usually  take  the  form  of  diffuse  growths  of  various  sizes 
throughout  the  peritoneum.  The  primary  malignant 
growths  are  usually  endotheliomata,  forming  dense  plate- 
like thickenings   of  the   peritoneum. 

The  benign  tumours  usually  originate  in  the  subserous 
tissue,  and  may  attain  large  dimensions  ;  they  are  usually 
solitary.  The  cystic  growths  are  either  hydatids,  or  of 
serous,  hsemorrhagic,  or  chylous  nature,  developing  between 
the  layers  of  the  mesentery  and  the  omentum,  and  situated 
below  the  umbilicus. 

Clinical  Course. — The  development  of  malignant 
growth  is  almost  always  associated  with  marked  ascites, 
and  the  fluid  is  usually  haemorrhagic.  Large  masses  are 
often  palpable,  and  the  plate-like  masses  of  endothelioma 
are  most  often  found  in  the  hypogastrium.  As  a  rule, 
symptoms  referable  to  the  primary  growth  precede  the 
peritoneal  disease,  but  in  some  cases  it  is  impossible  to 
trace  the  origin  of  the  disease. 

The  solid  and  cystic  growths  of  the  omentum  and  mesen- 
tery are  distinguished  by  their  marked  mobility  ;  they  lie 


296  INDICATIONS    FOR    OPERATION    IN 

as  a  rule  about  the  level  of  the  umbilicus  or  below  it.  In 
about  seven-tenths  of  the  cases  they  give  rise  to  attacks  of 
severe  pain,  usually  associated  with  constipation.  Some- 
times the  growth  of  the  tumour  is  intermittent. 

Diagnosis. — The  presence  of  a  rapidly-increasing  haemor- 
rhagic  ascites,  which  does  not  diminish  under  treatment  with 
cardiac  and  diuretic  remedies,  and  re-collects  soon  after 
puncture,  is  almost  diagnostic  of  malignant  disease,  and 
the  diagnosis  will  be  confirmed  if  a  primary  growth  or 
metastases  are  discovered.  Sometimes  tumour  elements 
are  to  be  found  in  the  exudate.  Cachexia  usually  co-exists 
with  the  ascites. 

In  cirrhosis  of  the  liver  the  exudate  is  rarely  hsemor- 
rhagic,  and  the  spleen  is  hypertrophied  ;  the  discovery  of  a 
primary  cancer  will  distinguish  the  condition  from  tuber- 
cular peritonitis. 

Cysts  and  solid  growths  of  the  omentum  and  mesentery 
are  very  mobile  ;  pelvic  examination  will  distinguish  them 
from  ovarian  tumours.  If  the  large  bowel  is  blown  up  it 
is  found  encircling  the  growth  like  a  collar,  and  the  distended 
stomach  lies  above  it  ;  these  anatomical  points  will 
distinguish  it  from  a  pancreatic  cyst,  and  from  a  cyst  of 
the  liver.  In  children,  the  question  of  chronic  intussuscep- 
tion has  to  be  considered,  but  this  is  associated  with  a  train 
of  symptoms  which  is  absent  in  the  case  of  omental  and 
mesenteric  growths. 

INDICATIONS  FOR  OPERATION. 

When  the  condition  is  one  of  peritoneal  cancer  the  only 
justifiable  procedure  is  puncture  and  removal  of  the  fluid 
if  asphyxia  threatens. 

When  a  tumour  is  present  which  appears  to  have  had 
its  origin  in  the  omentum  or  mesentery,  operation  is  uncon- 
ditionally indicated  :  (i)  When  the  tumour  is  growing 
rapidly  ;  (2)  When  severe  pain,  repeated  vomiting,  and 
perhaps  slight  fluid  effusion  and  meteorism  suggest  torsion 
of  the  pedicle,  or,  in  the  case  of  cystic  growths,  suppuration ; 
(3)  When  the  discovery  of  cystic  swellings  in  other  organs 
points  to  the  hydatid  nature  of  the  growth. 

The  only  contra-indications  to  operation  in  the  case  of 
large  solid  growths  of  the  omentum  and  mesentery  are 
such  as  would  discountenance  laparotomy  in  general.     The 


DISEASES    OF    THE    PERITONEUM.  297 

solid  growths  are  removed  entirely  ;  the  cystic  growths 
are  either  dissected  out,  or,  if  this  is  impossible,  incised, 
sutured  to  the  abdominal  wall,  and  drained. 

Prognosis. — Results  of  operation. — The  drawing  off  of 
fluid  is  a  palliative  measure  which  often  gives  very  great 
relief  to  the  patient.  In  the  case  of  cystic  and  simple 
solid  growths  operation  is  often  very  successful ;  of  40 
such  cases  27  were  permanently  cured  (67  per  cent). 

Risks  of  operation. — The  statement  that  by  the  drawing 
off  of  haemorrhagic  effusion  a  risk  is  run  of  severe  consequent 
haemorrhage,  is  not  supported  by  my  own  experience,  and 
is,  at  any  rate,  not  to  be  feared  as  much  as  some  writers 
appear  to  suggest.  In  one  case  of  endothelioma  I  observed 
an  implantation  metastasis  develop  in  the  puncture  track. 

In  the  course  of  extirpating  a  tumour  the  mesenteric  vessels 
may  be  injured  and  the  bowel  deprived  of  its  nutrition  ; 
under  such  circumstances  resection  becomes  necessary. 

When  a  cyst  is  drained  the  sinus  may  persist  for  a  long 
time,  as  long  as  a  year  in  some  cases  ;  the  scars  left  are 
often  troublesome,  and  ventral  hernia  frequently  results. 

The  prognosis  of  operation  differs  much  (Blum),  according 
as  it  is  done  at  the  time  when  intestinal  obstruction  is 
present  (31  per  cent  of  recoveries),  or  during  quiescence  of 
symptoms  (75  per  cent  of  recoveries).  Death  may  occur 
from  shock  or  sepsis. 

Without  operation. — Abundant  and  increasing  ascites 
presses  on  the  diaphragm  and  causes  asphyxia.  If 
torsion  of  the  pedicle  of  a  tumour  occurs,  and  extirpation 
is  not  proceeded  with,  necrosis  and  fatal  peritonitis  may 
supervene.  In  the  case  of  hydatids  and  other  cysts,  suppura- 
tion and  septicaemia,  or  rupture  and  peritonitis,  are  always 
to  be  feared. 

LITERATURE. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoneums. 
2nd  Ed.     1903. 

V.  Blum.  Ueber  cystiche  Tumoren  des  Peritoneums.  Zusam- 
menfassendes  Referat.  Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
1902. 

Narath.     Lymphcysten.     Archiv  f.   klin.   Chir.     Bd.   1. 

Garre.  Echinococcen  der  Bauchhohle.  Archiv  f.  kUn.  Chir. 
Bd.  lix,  p.  393. 

Begouin.  Traitement  des  Tumeurs  SoUdes  ct  Liquides  du  Mesen- 
tfire.     Rev.  d.  Chir.     No.   3.     1898. 


298  INDICATIONS    FOR    OPERATION    IN 

Hanot.     Traite  de  Chirurgie.     T.  vii,  p.  294. 

SouPAULT  Des  Kystes  Hydatiques  du  Peritoine.  Gaz.  des 
Hopit.     No.  87,  1895. 

MoYNiHAN.  Mesenteric  Cysts.  Medico-Chirurg.  Society  of 
London,  May,  1897.  Tumours  of  the  Mesentery.  The  Medical 
Chronicle,   September,    1902. 

Bernavs.  Sarcoma  of  the  Mesentery.  Annals  of  Surgery,  June, 
1902. 

Cheinisse.  Des  Kystes  Hydatiques  de  la  Cavite  Abdominale. 
La  Semaine  Medicale,  No.  38,  1902. 

D'Urso.  Cisti  da  Echinococco  del  Mesentere.  II  Policlinico, 
Vol.  viii.,   1 90 1. 

Nallino.  SuUe  cisti  del  Mesenterio.  II  Policlinico,  Vol.  ix, 
Fasc.  I,  2,  1902. 


ASCITES. 

Etiology  and  Pathological  Anatomy. — Fluid  collec- 
tions in  the  abdomen  of  a  non-inflammatory  nature  occur 
as  a  result  of  obstruction  to  the  portal  circulation,  as  in 
portal  thrombosis  and  hepatic  disease,  or  as  part  of  a 
universal  dropsy  from  cardiac  and  renal  disease,  or  in 
general  cachexia.  A  non-inflammatory  ascites  also 
occasionally  occurs  in  young  girls  before  the  onset  of 
menstruation.  The  fluid  is  usually  of  a  light  yellow  colour 
and  clear,  its  specific  gravity  1005  to  1015,  and  contains  a 
relatively  small  amount  of  albumin  :  from  "i  per  cent  to  a 
maximum  of  2 '5  per  cent,  usually  less  than  i  per  cent.  In 
chylous  ascites  there  is  fat  in  the  fluid,  giving  it  a  milky 
appearance,  due  to  rupture  or  obstruction  of  lymphatic 
vessels. 

Clinical  Signs. — The  presence  of  free  fluid  in  the  peri- 
toneal cavity  is  shown  by  dullness  in  the  dependent  parts, 
which  varies  as  to  its  limits  with  changes  in  the  position 
of  the  patient.  When  the  amount  of  fluid  is  large  a  fluid 
wave  is  to  be  felt  on  percussing  the  abdomen.  The 
distension  of  the  abdomen  is  uniform,  the  umbilicus  pro- 
trudes, the  abdominal  wall  is  often  oedematous,  and  its  veins 
are  dilated.  If  there  is  some  general  affection  of  the 
circulation  there  is  usually  oedema  of  the  legs  in  addition 
to  ascites,  and  this  is  also  often  present  when  the  ascites 
is  due  to  renal  disease  or  general  cachexia.  When  the 
diaphragm  is  pushed  upwards  by  a  large  collection  of  fluid 
a  serious  embarrassment  of  respiration  results. 


DISEASES    OF    THE    PERITONEUM.  299 

Diagnosis. — The  clinical  signs  just  mentioned  are  as 
a  rule  sufficiently  clear  to  establish  the  diagnosis.  The 
absence  of  meteorism,  pain,  and  tenderness  to  pressure, 
exclude  peritonitis.  Vomiting  may  be  frequent  even  in 
ascites  due  to  circulatory  disturbance.  When  the  fluid 
is  present  in  small  quantity  it  may  be  difficult  to  detect  ; 
examination  in  the  half  upright  position,  and  palpation  by 
the  vagina  or  by  invaginating  the  scrotum,  may  be  useful 
under  such  circumstances. 

Cases  occur  of  fluid  collections  in  enormously  dilated 
intestine  which  may  be  difficult  to  distinguish  from  ascites  ; 
but  the  observation  that  in  the  latter  the  fluid  changes  its 
position  when  the  patient  is  moved,  and  makes  its  way 
to  whatever  is  the  most  dependent  part  for  the  time  being, 
will  usually  make  the  condition  clear,  and  careful  examina- 
tion on  the  same  lines  will  also  differentiate  cystic  tumours, 
an  enlarged  uterus,  and  a  dilated  bladder. 

INDICATIONS  FOR  OPERATION. 

Operative  treatment  for  ascites,  with  the  exception  of 
Talma's  operation,  which  is  discussed  in  the  section  on 
cirrhosis  of  the  liver,  is  confined  to  puncture  with  the 
trocar  or  permanent  drainage  through  cannulae.  Withdrawal 
of  the  fluid  is  justified  under  the  following  circumstances  : 
(i)  When  the  fluid  is  present  in  such  amount  that  asphyxia 
is  threatened  ;  (2)  When  a  large  ascites  remains  stationary 
or  increases,  in  spite  of  medical  treatm.ent  ;  (3)  In  cardiac 
and  renal  disease,  when  the  heart  is  embarrassed  and 
diuretics  fail  to  relieve  ;  (4)  In  pure  hepatogenous  ascites 
and  in  its  earlier  stages,  without  waiting  for  the  effect  of 
diuretics. 

Permanent  drainage  is  comparatively  rarely  necessary ; 
it  is  indicated  (True)  when  the  fluid  rapidly  reaccumulates 
after  puncture,  and  when  a  fistula  becomes  established  at 
the  point  of  previous  puncture. 

Contra-indications. — It  is  advisable  to  avoid  puncture,  if 
possible,  when  some  inflammatory  affection  of  the  abdominal 
parietes  or  other  parts  of  the  body  is  present.  Erysipelas 
of  the  extremities  is  not  uncommon  in  general  dropsy.  A 
tendency  to  gastric  and  intestinal  haemorrhages  also  contra- 
indicates  tapping,  as  intense  distension  of  the  abdominal 
vessels    always    follows    the    proceeding.     If    the    general 


300  INDICATIONS    FOR    OPERATION    IN 

condition  is  very  bad,  puncture  should  be  repeated  as 
infrequently  as  possible  on  account  of  the  loss  of  albumin. 
The  ascites  of  young  girls  does  not  call  for  tapping ;  it  may 
disappear  spontaneously  when  menstruation  begins. 

Prognosis. — Results  and  risks  of  abdominal  puncture. — In 
cirrhosis  of  the  liver,  permanent  relief  sometimes  follows 
several  tappings  if  appropriate  dietetic  treatment  is  instituted 
at  the  same  time.  Circulatory  compensation  may  follow  the 
relief  given  by  tapping  in  diseases  of  the  heart  and  kidneys. 
In  a  case  of  mitral  stenosis  and  incompetence  under  my  care 
the  abdomen  was  tapped  for  the  relief  of  intense  dyspnoea, 
and  for  several  years  afterwards  there  was  no  return  of  the 
ascites.  Sudden  severe  collapse  may  follow  tapping  if  the 
precaution  of  moderately  compressing  the  abdomen  after- 
wards is  not  taken.  Even  when  tapping  is  done  with 
careful  aseptic  precautions  a  non-purulent  peritonitis  may 
ensue  after  it  has  been  done  several  times.  The  deep 
epigastric  artery  has  occasionally  been  wounded  The 
puncture  hole  sometimes  leaks  for  several  days  ;  eczema 
of  the  surrounding  skin  and  secondary  infections  occasionally 
occur. 

Prognosis  without  puncture. — Although  a  patient  with 
ascites  may  live  long,  the  condition  remains  always  a 
great  menace  to  life  if  unrelieved  ;  oedema  of  the  lower 
extremities  supervenes,  and  the  heart  becomes  embarrassed. 
Hernia  may  occur  from  diastasis  of  the  recti ;  occasionally 
ascitic  fluid  makes  its  way  to  the  exterior  through  the 
umbilicus  ;  I  have  twice  seen  this  occur  without  untoward 
result. 

LITERATURE. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  Peritoneums.  2nd 
Ed.     Wien,  1903. 

GuMPRECHT.  Die  Technik  der  speziellen  Therapie.  3rd  Ed. 
Jena,  1903. 

Bargebuhr.  Ascytes  Chylosus.  Deutsches  Arch.  f.  klin. 
Med.,  Bd.  li. 

Quincke.     Ascites.     Ibidem.     Bd.    xxxvi. 

Ilo  und  Ousi.  Zur  chirurgischen  Behandlung  des  Ascites. 
Deutsche  Zeit.  f.  Chir.     Bd.  Ixii. 

Cheadle.  Prognosis  and  Treatment  of  Ascites.  Brit.  Med. 
Jour.     Vol.  ii,  p.  1102.      1892. 

Thomson.  Prognosis  and  Treatment  of  Cirrhotic  Ascites.  Lancet, 
June  15,   1901 


DISEASES    OF    THE    PERITONEUM  ,  301 

SUBPHRENIC    ABSCESS. 

Etiology. — Subphrenic  abscess  is  caused  by  inflam- 
matory affections  of  the  abdominal  cavity,  appendicitis, 
disease  of  the  genital  organs,  cholecystitis,  hepatic  and 
splenic  abscess.  Many  cases  are  due  to  chronic  perforation 
of  gastric  and  intestinal  ulcers.  In  rare  cases  it  occurs  in 
the  course  of  a  general  septic  infection  or  as  a  result  of 
trauma. 

Pathological  Anatomy. — The  abscess  may  be  intra- 
peritoneal or  retroperitoneal ;  it  may  reach  large  dimensions, 
and  may  be  loculated.  It  is  often  connected  by  fistulous 
tracks  with  other  intra-  or  extraperitoneal  purulent  collec- 
tions. The  pus  may  make  its  way  into  the  pleural  cavity, 
and  there  set  up  a  subpleural  abscess  or  an  empyema, 
or  a  pneumothorax.  Rupture  into  the  lung  and  discharge 
through  a  bronchus  is  also  fairly  common.  The  pus  often 
has  a  faecal  odour,  and  the  abscess  frequently  contains  air. 
The  condition  is  often  bilateral ;  perforation  of  the  dia- 
phragm may  occur  at  several  separate  points.  Sub- 
phrenic suppuration  secondary  to  a  suppurative  process 
in  the  thorax  is  extremely  rare. 

Abscesses  on  the  left  side  are  usually  connected  with 
the  stomach,  abscesses  on  the  right  with  the  appendix,  the 
liver,  or  the  duodenum. 

Clinical  Course. — The  symptomatology  of  subphrenic 
abscess  is  extremely  variable.  As  a  rule  the  temperature 
is  high  ;  pain  may  be  complained  of  over  the  lower  ribs, 
but  is  often  entirely  absent.  The  diaphragm  is  usually 
considerably  pushed  upwards  ;  the  liver  and  spleen  are 
commonly  depressed,  the  heart  dislocated  upwards,  and  to 
the  side.  When  the  abscess  is  on  the  right  side  the  liver 
dullness  is  often  continuous  upwards  towards  the  axilla  in 
the  form  of  an  arc,  declining  towards  the  back,  A  sign 
of  much  importance  is  oedema  of  the  overlying  soft  parts, 
particularly  common  when  the  abscess  is  retroperitoneal. 

Diagnosis. — The  condition  will  always  be  suspected 
when  relief  is  not  afforded  by  the  local  treatment  of 
suppurative  foci  in  the  abdomen,  especially  suppurative 
appendicitis.  When  the  general  symptoms  of  such  affec- 
tions persist,  the  physical  signs  of  subphrenic  suppuration 
will  be  sought  for,  and  if  found,  in  association  with  marked 


302  INDICATIONS    FOR    OPERATION    IN 

leucocytosis,  the  diagnosis  is  practically  certain.  Radio- 
graphic examination  will  prove  of  value.  Strong 
corroboration  will  be  afforded  by  the  presence  of  cutaneous 
oedema. 

Air  in  the  abscess  will  give  characteristic  physical  signs, 
similar  to  those  of  pneumothorax. 

If  rupture  takes  place  into  the  thoracic  cavity  and 
symptoms  of  pneumothorax  develop,  the  diagnosis  will  be 
clear.  Sometimes  a  subphrenic  abscess  is  associated  with 
a  serous  pleural  effusion. 

Lately  a  young  man  was  admitted  to  hospital  under 
my  care  with  high  fever.  At  the  base  of  the  chest  behind 
there  was  dullness  and  diminished  breath  sounds,  and  on 
puncture  here  a  sterile  serous  exudation  was  removed. 
As  there  was  some  tenderness  on  pressure  and  slight  resis- 
tance in  the  region  of  the  left  kidney,  I  made  a  diagnosis  of 
perinephritis  and  probable  subphrenic  abscess,  with  secondary 
serous  pleurisy.  The  resistance  became  more  marked, 
the  fever  persisted,  and  the  soft  parts  in  the  loin  became 
oedematous.  Incision  was  made  here,  and  more  than  half 
a  litre  of  pus  was  evacuated,  the  abscess  extending  upwards 
into  the  dome  of  the  diaphragm.     The  patient  recovered. 

In  view  of  such  cases,  when  a  subphrenic  abscess  is 
suspected,  puncture  should  be  made  in  the  lower  spaces  if 
serous  fluid  is  first  obtained  above  ;  I  have  several  times 
demonstrated  an  abscess  in  this  manner. 

It  is  sometimes  very  difficult  to  differentiate  between 
subphrenic  pyopneumothorax  and  an  encysted  pyopneumo- 
thorax at  the  base  of  the  lung ;  the  history  of  the  earlier 
symptoms,  whether  they  have  been  abdominal  or  pulmonary, 
must  be  enquired  into.  A  liver  abscess  which  does  not 
contain  gas,  and  which  is  situated  close  under  the  diaphragm, 
cannot  be  distinguished  from  a  subphrenic  abscess  with 
certainty,  and  the  two  are  in  fact  often  associated. 

INDICATIONS  FOR  OPERATION. 

As  soon  as  the  diagnosis  is  made  of  a  purulent  inflamma- 
tion which  may  lead  on  to  subphrenic  abscess,  operation  is 
urgently  called  for  If  the  patient  already  presents  signs 
of  subphrenic  abscess  when  first  seen,  it  is  necessary  to 
freely  open  the  collection  at  once  and  drain  it.  The  incision 
will  either  be  carried  through  the  pleura  or  will  be  made 


DISEASES    OF    THE    PERITONEUM.  303 

below  the  costal  border,  according  to  the  situation  of  the 
abscess. 

Since  it  has  become  the  habit  to  treat  cases  of  suppurative 
appendicitis    and   other   abdominal   suppurative   affections 
by  early  operation,  subphrenic  abscess  has  become  much 
less    common    than    previously.     Its    best    treatment    is 
prophylactic. 

It  must  not  be  forgotten  that  bilateral  abscess  is  not  rare, 
and  that  after  one  side  has  been  opened  suppuration  may 
continue  to  extend  on  the  other  side,  necessitating  a  second 
incision. 

Contra-indications. — Subphrenic  abscess  is  associated  with 
such  grave  risk  to  life  that  operation  is  only  contra-indicated 
if  the  patient  is  actually  moribund.  Perhaps  in  an  extremely 
feeble  patient  it  is  legitimate  to  temporize  if  pus  is  discharg- 
ing by  the  bowel,  but  the  collection  usually  forms  anew  and 
gives  rise  to  dangerous  complications  again. 

Prognosis. — Results  of  operation. — Operation  is  often  suc- 
cessful in  saving  life  in  subphrenic  abscess  ;  when  there  is  a 
pneumothorax,  or  a  fistula  between  intestine  and  bronchus, 
or  some  other  complication  involving  the  thoracic  organs, 
operation  usually  palliates  but  does  not  cure.  Other 
suppurative  foci  are  often  associated  with  the  subphrenic 
collection,  and  the  opening  of  the  latter  may  be  followed 
by  no  improvement  if  others  persist. 

In  a  young  girl  under  my  observation  appendicitis  was 
followed  by  a  slowly  progressive  purulent  peritonitis.  The 
clinical  signs  pointed  to  a  right-sided  subphrenic  abscess, 
and  a  second  larger  collection  to  the  left  side  of  the  urinary 
bladder.  The  right  subphrenic  abscess  was  opened  by  the 
surgeon,  and  another  large  abscess  on  the  left,  apparently 
not  subphrenic.  The  girl  improved,  and  the  temperature 
fell.  On  the  sixth  day  there  developed  intense  dyspnoea, 
and  death  followed.  The  autopsy  showed  that  a  small 
subphrenic  abscess  had  ruptured  into  the  left  pleura,  and 
that  this  abscess  cavity  communicated  with  the  other 
abscess  on  the  left  side,  which  had  been  opened,  by  a  fistulous 
track. 

On  the  other  hand,  a  subphrenic  abscess,  even  when 
associated  with  severe  complications,  may  be  successfully 
dealt  with  by  operation.  In  a  recent  case  which  I  saw,  a 
subphrenic   abscess,  apparently  originating  from  the  liver. 


304  INDICATIONS    FOR    OPERATION. 

ruptured  into  the  left  pleura,  and  produced  a  large  empyema  ; 
three  ribs  were  excised,  the  empyema  was  drained,  and  the 
patient  recovered.  In  general  the  prognosis  depends  upon 
the  condition  of  the  patient,  the  size  of  the  abscess,  the 
nature  of  the  original  disease,  and  the  complications  present. 
In  60  cases  operated  on  by  Korte  40  recovered,  20  died. 
Of  75  cases  collected  by  Maydl  35  died  (47  per  cent).  The 
least  favourable  cases  are  those  in  which  the  intestine 
(except  the  appendix)  is  the  point  of  origin  of  the  abscess. 
In  addition  to  the  danger  of  collapse,  there  is  a  risk  of 
infecting  the  general  peritoneal  cavity  if  adhesions  are 
torn  during  operation. 

Without  operation. — In  rare  cases  spontaneous  recovery 
has  followed  after  rupture  of  the  abscess  into  the  bowel, 
the  exterior,  a  bronchus,  or  the  stomach.  Thoracic  complica- 
tions are  the  cause  of  fatality  in  many  cases  ;  in  others 
general  pyaemia  is  the  cause  of  death. 

LITERATURE. 

NoTHNAGEL.  Erkrankungen  des  Darmes  und  des  Peritoncums. 
2nd  Ed.     Wien,  1903. 

Maydl.     Subphrenische  Abscesse.     Wien,  1894. 

Umber.  Pyopneumothorax  Subphrenicus.  Mitteil.  a.  d.  Grenz- 
gebiete  d.  Med.  u.  Chir.     Bd.  vi. 

Mason.  Cases  of  Subdiaphragmatic  Abscess.  Boston  Medical 
and  Surgical  Journal,  Vol.  cxxi,  pp.  149  and  469. 

Meltzer.  On  Subphrenic  Abscess.  New  York  Med.  Jour., 
June  24,  1893. 

Sachs.  Der  Subphrenische  Abscess.  Archiv  fiir  Klinische 
Chirurgie.     Bd.  1. 

V.  Leyden  und  Renvers.  Ueber  Pyopneumothorax  Sub- 
phrenicus und  dessen  Behandlung.  Berl.  klin.  Wochens.,  No.  46 
(mit  Diskussion),  1892. 

WiNKELMANN.  Zur  Kasulstik  der  operativ  Behandelten  sub- 
phrenischen  Abscesse.     Deut.  med.  Wochens.,  29  Jahrgang,  No.  7. 

MuscHER.  Pneumothorax  Sousphrenique.  Gazette  Medicale  de 
Paris,  p.  529,  1895. 

Lejars.  Le  Suppurations  de  la  Zone  Sousphrenique.  La 
Semaine  Medicale,  No.  13,  1Q02. 


CHAPTER    XVIII. 
Diseases  of  the  Gall-Bladder  and  Bile-Ducts. 


307 


Chapter  XVIII. 

DISEASES    OF    THE    GALL-BLADDER    AND 
BILE-DUCTS. 

CHOLELITHIASIS    (GALL-STONES). 

Etiology. — The  formation  of  gall-stones  is  favoured  by 
stasis  of  the  bile ;  micro-organisms,  and  particularly  the 
Bacillus  coli,  play  a  part  in  their  production,  and  probably 
reach  the  gall-bladder  from  the  intestine.  The  affection  is 
more  common  in  women  than  in  men ;  it  is  rare  in  childhood, 
and  becomes  steadily  more  frequent  as  advanced  age  is 
approached.  Tight  clothes,  particularly  corsets  and  belts, 
appear  to  play  some  part  in  etiology ;  also  pregnancy,  a 
sedentary  life,  and  the  feebleness  of  abdominal  muscles 
found  in  old  age.  Another  apparent  causative  factor  is  the 
uric  acid  diathesis,  and  many  authors  have  credited  heredity, 
atheroma,  and  incontinent  habits  of  life  with  a  similar 
influence.  In  rare  instances  foreign  bodies  have  reached 
the  biliary  channels  and  have  caused  gall-stone  formation. 
Attacks  of  colic  may  be  set  up  by  injury,  and  possibly  also 
by  emotional  influences. 

Pathological  Anatomy. — Gall-stones  are  formed  in  the 
gall-bladder  and  are  most  often  found  there,  but  also  in  the 
cystic  and  common  bile-ducts  ;  stones  of  secondary  forma- 
tion are  not  uncommonly  found  in  the  intrahepatic  bile- 
ducts.  Usually  the  stones  are  multiple  and  faceted,  but 
it  is  not  unusual  to  find  a  single  stone  ;  this  may  reach  the 
size  of  a  walnut,  and  it  is  usually  rough  on  the  surface. 
When  a  single  calculus  is  lodged  in  the  neck  of  the  bladder 
it  often  attains  large  dimensions  ;  when  a  stone  is  thus 
lodged  other  stones  often  form  within  the  bladder,  but  only 
rarely  forwards  in  the  cystic  duct.  Stones  appear  to  form 
in  batches  ;    the  gall-bladder  itself  may  meanwhile  be  little 


3o8  INDICATIONS    FOR    OPERATION    IN 

changed,  but  when  an  "  attack  "  occurs  there  is  inflammatory 
sweUing  of  the  mucous  membrane,  with  effusion  of  serous  or 
purulent  fluid.  Inflammation  of  the  gall-bladder  may  be 
serous,  seropurulent,  purulent,  septic,  or  diphtheritic  ;  it 
often  spreads  to  surrounding  parts,  and  adhesions  form 
which  interfere  with  the  flow  of  bile,  particularly  by  causing 
kinking  of  the  cystic  duct.  In  recent  inflammation  the 
gall-bladder  is  distended,  often  cucumber-shaped,  and  the 
walls  are  thinned ;  repeated  attacks  lead  to  cicatricial 
shrinking.  After  the  passage  of  calculi  the  cystic  duct  may 
remain  enormously  dilated,  or  may  be  constricted  and  even 
obliterated  by  the  cicatrization  of  ulceration  ;  ulceration 
may  lead  to  the  formation  of  a  choledocho duodenal  fistula. 

The  gall-bladder  may  entirely  get  rid  of  its  stones  by  the 
ducts  into  the  intestine,  and  the  affection  be  spontaneously 
cured.  Not  uncommonly  chronic  perforation  of  the  bladder, 
more  rarely  of  the  cystic  duct,  takes  place,  with  the  formation 
of  an  intestinal  fistula  ;  occasionally  a  fistula  is  connected 
with  other  organs  ;  acute  rupture  into  the  peritoneal  cavity 
is  rare. 

If  a  stone  remains  a  long  time  in  the  neck  of  the  gall- 
bladder an  inflammatory  hydrops  occurs,  or,  in  case  of 
infection,  an  empyema.  In  183  cases  of  stone  in  the 
bladder  neck  and  cystic  duct,  operated  on  by  Riedel,  there 
was  bile  in  the  bladder  in  27,  and  serous  or  purulent  fluid 
in  156.  When  a  stone  is  lodged  in  the  common  duct, 
inflammatory  affections  of  the  surrounding  structures  are 
not  uncommon ;  in  particular,  chronic  pancreatitis  and 
thrombosis  of  the  portal  vein  ;  the  bile-ducts  above  may 
also  be  infected,  leading  to  an  infective  cholangitis  and  liver 
abscess.  In  purulent  cholangitis  inflammatory  changes  are 
often  found  in  distant  organs  :  the  kidney,  the  endocardium, 
and  the  lung  (abscess).  In  old-standing  cases  of  chole- 
lithiasis, carcinoma  of  the  gall-bladder  is  often  found  at 
autopsy. 

Clinical  Course. — In  many  cases  gall-stones  cause  no 
symptoms.  Often  there  is  only  a  dull  pain,  which  the 
patient  refers  to  the  stomach.  The  attacks  of  colic  are 
characteristic,  sometimes  mild  in  type,  sometimes  agonizing  ; 
their  intensity  bears  no  relation  to  the  extent  of  the  affection 
present  ;  they  are  localized  in  the  region  of  the  gall-bladder. 
In  this  region  also  there  is  tenderness  on  pressure,  and  often 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     309 

a  tumour.  As  a  rule,  vomiting  accompanies  the  attacks. 
If  the  bladder  is  infected  there  is  fever,  often  intermittent 
in  type,  and  frequently  there  are  signs  of  the  spread  of 
the  inflammatory  process  to  surrounding  parts  :  meteorism, 
constipation,  and  perihepatic  friction.  Jaundice  is  absent 
in  most  cases  of  gall-stone  colic,  but  if  the  stone  reaches  the 
common  duct  it  is  usually  present  along  with  enlargement 
of  the  liver  ;  this,  however,  is  not  always  the  case  even  with 
large  stones.  When  a  stone  is  long  impacted  in  the  common 
duct  the  jaundice  is  intense,  fever  is  often  pronounced,  and 
in  late  stages  there  may  be  hsemorrhages  from  the  mucous 
membranes.  When  the  common  duct  is  thus  blocked,  the 
gastric  and  intestinal  functions  are  interfered  with,  and 
when  the  condition  is  prolonged  the  patient's  general  state 
of  health  suffers  very  much. 

It  is  not  common  for  stones  to  be  evacuated  through  the 
intestine  ;  if  such  a  stone  is  larger  than  a  cherry-stone  it 
will  probably  have  made  its  way  through  a  fistulous  opening 
into  the  intestine  ;  such  fistulse  may  develop  early  or  late 
in  the  progress  of  the  disease,  and  may  give  rise  to  no 
particularly  troublesome  symptoms. 

The  intervals  between  attacks  of  colic  are  variable ; 
frequently  an  interval  is  as  long  as  a  year.  If  during  this 
time  the  cystic  duct  is  blocked  and  the  inflammatory 
reaction  subsides,  a  painless  distended  gall-bladder  may 
persist,  but  in  many  such  cases  the  tumour  which  is  present 
in  the  early  stages  subsides  and  disappears  after  a  few  days. 
Riedel  distinguishes  between  the  "  unsuccessful "  attacks, 
in  which  the  stone  does  not  pass  beyond  the  cystic  duct, 
and  the  "  successful,"  in  which  it  reaches  the  common  duct 
or  the  intestine. 

Diagnosis. — In  a  period  of  quiescence  diagnosis  may  be 
impossible  if  there  is  no  exact  history,  as  local  signs  may  be 
entirely  wanting  ;  but  often  it  is  possible  to  elicit  tenderness 
over  the  gall-bladder  when  an  attempt  is  made  to  press 
up  the  liver  during  inspiration.  The  history  is  often 
characteristic  ;  if  the  patient  tells  a  story  of  attacks  of 
pain  in  the  stomach  region,  accompanied  by  vomiting  and 
jaundice,  which  have  been  going  on  for  a  year  or  more,  the 
condition  is  in  all  probability  cholelithiasis.  The  diagnosis 
is  made  clear  by  the  discovery  of  calculi  in  the  faeces,  or  by 
the  presence  of  a  painful  pyriform  tumour  in  the  gall-bladder 


3IO  INDICATIONS    FOR    OPERATION    IN 

region.  Such  a  tumour  may  have  a  characteristic  mobihty, 
pressure  with  the  hand  causing  it  to  disappear,  to  reappear 
shortly  in  its  former  position ;  it  is  often  hard,  but  I  have 
never  been  able  to  make  out  the  grating  of  the  calculi  on 
each  other  so  often  described  by  writers.  Exploratory 
puncture  is  inadvisable,  owing  to  the  risk  of  infecting  the 
peritoneum.  Biliary  calculi  have  hardly  ever  been  demon- 
strated by  radiograph. 

General  diagnosis  is  not  all  that  is  necessary ;  an  attempt 
must  be  made  to  diagnose  the  exact  local  condition  present ; 
the  following  points  are  based  on  the  descriptions  of  Kehr  : — 

Acute  obstruction  of  the  common  duct  is  characterized  by 
the  appearance  of  intense  jaundice  following  or  during  a 
typical  attack  of  colic  associated  with  vomiting,  often  with 
fever,  and  the  radiation  of  pain  to  the  chest  and  back. 

In  chronic  obstruction  of  the  common  duct  there  is  often 
no  enlargement  of  the  gall-bladder  and  liver  ;  the  former 
is,  in  fact,  often  shrunken  ;  there  is  intermittent  fever. 
Jaundice  and  decoloration  of  faeces  vary  in  degree  from 
time  to  time  ;  the  patient  usually  complains  of  a  dull 
epigastric  pain,  and  the  spleen  is  often  enlarged.  Cachexia 
is  frequently  present  and  a  tendency  to  haemorrhage  from 
the  mucous  membranes. 

In  acute  cholecystitis  of  a  gall-bladder  previously  more 
or  less  normal,  a  tumour  forms ;  there  is  no  enlargement 
of  the  liver,  but  a  tongue-like  process  of  liver  substance 
(Riedel's  lobe)  may  project  downwards  in  front  of  the  gall- 
bladder. Jaundice  is  present  in  only  about  lo  per  cent  of 
cases;  when  this  jaundice  is  associated  with  a  palpable 
gall-bladder  tumour  it  is  usually,  according  to  Riedel, 
inflammatory  in  origin  and  nature.  There  is  always  acute 
pain  and  tenderness,  sometimes  peritoneal  friction,  and 
usually  fever,  with  general  constitutional  disturbance. 

Acute  cholecystitis  of  a  shrunken  gall-bladder  is  usually 
associated  with  obliteration  or  constriction  of  the  cystic 
duct,  and  the  presence  of  multiple  adhesions  around  the 
bladder.  As  a  rule,  there  is  no  gall-bladder  tumour  and  no 
jaundice,  but  there  is  definite  local  tenderness  to  pressure. 
When  there  is  a  collection  of  pus  in  the  bladder  there  is 
usually  high  fever,  and  when  the  affection  is  of  a  severe  type 
it  will  be  associated  with  rigors  and  pronounced  symptoms 
of  septic  intoxication. 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     311 

Empyema  of  the  gall-bladder  associated  with  calculi  is 
characterized  by  the  presence  of  a  tender  swelling  in  the 
gall-bladder  situation,  and  subjective  pain  referred  chiefly 
to  the  same  spot.  Fever  and  rigors  commonly,  but  not 
invariably,  occur,  and  often  there  are  signs  of  a  local 
peritonitis,  with  meteorism,  vomiting,  slight  ascites,  and 
perihepatic  friction.  As  a  rule,  the  calculi  do  not  pass  into 
the  intestine. 

Acute  perforation  of  the  gall-bladder  gives  rise  to  sudden 
excessively  severe  local  pain,  with  collapse,  rapid  pulse,  and 
subnormal  temperature.  The  abdominal  wall  is  rigid,  and 
after  a  time  some  distension  appears  and  there  are  signs  of 
free  fluid  in  the  peritoneal  cavity. 

In  a  patient  of  mine,  about  30  years  of  age,  the  family 
medical  attendant  had  for  several  years  suspected  gall- 
stones, and  several  courses  of  treatment  at  Carlsbad  had 
been  undergone.  Finally,  the  pain  becoming  much  worse, 
and  being  associated  with  fever,  he  came  from  Roumania 
to  Vienna.  When  seen  he  had  had  fever  for  fourteen  days, 
ushered  in  by  a  single  rigor  ;  there  was  a  firm,  tender 
swelling  in  the  gall-bladder  region,  no  jaundice,  no  ascites, 
no  collapse.  Immediate  operation  was  advised,  but  was 
not  agreed  to  until  eight  days  later,  when  the  general  con- 
dition was  worse  and  the  pain  intense,  though  not  exactly 
insupportable.  At  the  operation  a  perforation  of  the  gall- 
bladder was  found,  the  resulting  peritonitis  being  localized 
by  adhesions.  Both  within  and  outside  the  gall-bladder 
there  were  numerous  calculi,  small  and  large,  and  a  quantity 
of  foetid  pus.     The  patient  recovered. 

Chronic  obstruction  of  the  cystic  duct  is  characterized  by 
hydrops  of  the  gall-bladder  forming  a  cystic  tumour  ;  the 
most  common  symptom  is  an  indefinite  epigastric  pain. 
There  is  no  enlargement  of  the  liver  or  jaundice.  A 
"  Riedel's  lobe  "  is  often  present. 

The  groups  of  symptoms  which  have  been  mentioned  are 
those  which  are  generally  characteristic  of  the  lesions  noted, 
but  they  must  not  be  looked  upon  as  absolutely  diagnostic 
of  these  particular  lesions. 

In  general  it  should  be  noted  that  the  presence  of  a 
distended  gall-bladder  in  a  first  attack  points  to  a  severe 
inflammatory  condition  of  the  bladder  which  may  be  serous 
or  purulent.     A  distended  gall-bladder  in  a  case  of  chronic 


312  INDICATIONS    FOR    OPERATION    IN 

recurrent  cholelithiasis  usually  means  a  serous  exudation 
if  there  is  no  jaundice  ;  more  rarely  an  empyema.  If 
jaundice  is  present  in  such  a  case  it  will  be  of  the  "  infia  m- 
matory  "  type,  and  in  either  case  there  will  be  a  calculus  in 
the  cystic  duct  or  the  neck  of  the  bladder.  The  disappear- 
ance of  a  gall-bladder  tumour  when  jaundice  persists  or 
increases  indicates  the  passage  of  the  obstructing  calculus 
into  the  common  duct  towards  the  duodenum.  Inter- 
mittent fever  with  rigors  may  be  associated  with  calculus 
in  any  situation,  and  points  to  the  occurrence  of  suppuration. 

Differential  Diagnosis.— In  an  attack  of  colic  the  question 
will  arise  as  to  the  possibility  of  its  being  of  renal  origin. 
Renal  colic  is  distinguished  by  frequency  of  micturition, 
scanty  urine,  rectal  tenesmus,  radiating  pain  along  the 
ureter  to  the  glans  penis,  and  tenderness  on  pressure 
over  the  kidney  and  often   along  the  ureter. 

In  appendicitis  the  situation  of  the  pain  and  tenderness 
is  lower  in  the  abdomen  and  more  lateral ;  dullness  on 
percussion,  if  present,  is  in  the  right  iliac  fossa,  and  the 
enlarged  appendix  can  often  be  felt. 

In  intestinal  colic  meteorism  is  often  present,  and  pressure 
on  the  abdomen  lessens  the  pain,  which  passes  off  with 
intestinal  gurgling  ;  if  there  is  actual  bowel  stenosis  there 
will  be  excessive  peristaltic  movements. 

A  movable  kidney  will  be  distinguished  by  its  shape,  but 
a  hydronephrotic  kidney  may  resemble  the  outline  of  a 
distended  gall-bladder.  Such  a  renal  tumour  can  often  be 
pushed  upwards  under  the  liver,  and  is  obscured  by  distension 
of  the  colon  and  small  bowel,  whereas  a  gall-bladder  tumour 
remains  prominent  under  these  conditions.  In  tumours  of 
the  stomach  and  pylorus  the  diagnosis  will  be  assisted  by 
inflating  the  stomach,  by  chemical  examination  of  the 
stomach  contents,  by  attention  to  the  history,  and  by  the 
presence  of  exaggerated  stomach  peristalsis.  Hydatid  cysts 
of  the  liver  can  usually  be  distinguished  by  the  history  of  a 
slow-growing,  painless  tumour,  associated  with  a  relatively 
good  general  condition  and  the  probability  of  echinococcus 
infection. 

Tumours  of  the  omentum  when  displaced  with  the  hand 
do  not  usually  return  to  the  same  spot  in  the  way  that  is 
characteristic  of  gall-bladder  tumours. 

Carcinoma  of  the  gall-bladder  and  liver  is  distinguished 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     SU 

from  cholangitis  by  the  intense  hardness  of  the  tumour 
present  in  the  gall-bladder  region  and  by  the  onset  of  ascites. 
Sometimes  hysterical  gastralgia  may  be  simulated  by  gall- 
stone colic,  with  obstruction  of  the  cystic  duct,  as  in  a  case 
under  my  care,  in  which  the  pains  due  to  calculus  were  for 
several  years  ascribed  to  the  former  condition, 

INDICATIONS   FOR   OPERATION. 

There  is  a  considerable  amount  of  disagreement  as  to  the 
indications  for  operation  in  cases  of  gall-stone  disease. 
There  are  many  who  disagree  with  Winiwater's  view,  that 
the  presence  of  gall-stones  constitutes  in  itself  a  sufficient 
indication  for  operation,  and,  in  view  of  the  many  cases  in 
which  calculi  cause  no  symptoms,  this  opinion  is  certainly 
extreme  ;  Korte's  opinion  is  that  the  necessity  for  operation 
should  be  judged  from  the  type  and  degree  of  inflammatory 
disturbance  caused  by  calculi,  either  periodically  or 
persistently. 

Riedel  advocates  early  operation  ;  he  considers  that  an 
attack  of  colic  calls  for  operative  interference  if  no  small 
stones  are  evacuated,  either  during  or  immediately  after 
the  attack  ;  but  as  many  patients  have  only  a  single  attack, 
and  without  getting  rid  of  calculi  have  no  further  troubles  of 
the  kind,  in  the  opinion  of  many  physicians,  including  myself, 
such  a  single  attack  is  not  a  sufficient  indication.  Signs  of 
infection  may  follow  operation  in  cases  which  had  been  free 
from  any  such  signs  before.  Riedel's  statement  that  nine- 
tenths  of  cases  of  gall-stones  require  operation,  requires 
more  evidence  to  support  it  than  has  yet  been  advanced. 
Kehr  holds  that  there  is  an  absolute  indication  for  operation 
under  the  following  conditions  :  (i)  In  acute  purulent 
cholecystitis  and  in  chronic  obstruction  of  the  cystic  duct, 
internal  treatment  being  useless  in  either  case  ;  (2)  In 
persistent  colic,  or  continuous  pain,  when  internal  treatment 
gives  no  relief,  particularly  when  it  renders  the  patient  unfit 
for  work,  or  if  the  patient  has  developed  morphine  hunger 
and  himself  desires  operation  ;  (3)  When  a  firm  gall-bladder 
tumour  gives  rise  to  a  suspicion  of  carcinoma,  and  when 
there  are  signs  of  perforation  or  suppuration  in  the  surround- 
ing parts. 

The  first  of  these  indications  is  incontestable ;  and  opera- 
tion is  called  for  also  in  the  cases  of  "  quiet  "  common  duct 


314  INDICATIONS    FOR    OPERATION    IN 

obstruction,  characterized  by  chronic  jaundice  without 
fever,  loss  of  flesh,  and  absence  of  bile  from  the  stools 
following  an  attack  of  colic ;  and  equally  in  common  duct 
obstruction  complicated  by  infection.  When  suppuration 
is  suspected,  a  rapidly  increasing  leucocytosis  indicates  early 
operation,  and  this  is  specially  important  in  relation  to  the 
chronic  apjTexic  empyema  of  the  gall-bladder.  Kehr's 
second  indication  is  of  special  importance  in  dealing  with 
the  w^orking  classes,  and  wdth  patients  on  whom  the  affection 
has  a  specially  marked  effect,  physically  or  morally.  In 
such  cases  it  may  be  necessary  to  operate  even  when  the 
diagnosis  is  not  very  clear.  Operation  must  always  be 
advised  in  these  patients  w'hen,  in  addition  to  pain,  there 
are  signs  of  gastric  stasis  from  obstruction  at  the  pylorus,  a 
state  of  affairs  which  wdll  increase  in  severity  if  left  alone. 
Regarding  the  third  class,  Kehr  himself  is  somewhat 
doubtful  as  to  the  indications  to  be  based  on  a  probably 
cancerous  tumour  ;  by  the  time  such  a  tumour  is  discovered 
the  time  for  successful  removal  has,  as  a  rule,  passed. 

With  regard  to  the  time  for  operation  in  persistent 
jaundice,  Ewald's  opinion  should  be  borne  in  mind,  that 
operation  should  never  be  delayed  more  than  a  month  ;  if 
it  is  put  off  longer  the  prospect  of  healing  becomes  bad, 
there  is  risk  from  hgemorrhage,  sutures  tear  through,  and 
adhesions  do  not  form. 

Operative  Methods. — When  the  wall  of  the  gall-bladder 
is  sound,  cystostomy  is  performed  either  in  one  or,  less 
commonly,  in  two  stages,  and  the  calculi  are  removed  from 
the  bladder  and  the  cystic  duct.  When  a  stone  is  in  the 
cystic  duct  the  duct  itself  has  often  to  be  incised.  Cyst- 
ectomy is  a  more  dangerous  procedure  ;  it  is  necessary  when 
the  gall-bladder  is  shrunken,  brittle,  or  fistulous,  whether 
there  are  calculi  within  it  or  not,  and  when  the  cystic  duct 
is  obliterated,  or  has  been  long  obstructed  by  a  stone. 
Cholecystenterostomy  is  sometimes  called  for  in  cases  of 
chronic  obstruction  of  the  common  duct  when  the  duct  is 
inaccessible.  Suppuration  around  the  gall-bladder  may  be 
dealt  wdth  in  one  or  two  stages,  the  pus  being  first  evacuated, 
and  the  gall-bladder  itself  being  opened  later.  In  chronic 
obstruction  of  the  common  duct  choledochotomy,  with 
drainage  of  the  hepatic  duct,  is  called  for ;  this  is  the 
most    difficult    of   the    operations    on    the    bile-ducts.     In 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     315 

almost  all  operations  on  the  bladder  and  ducts  drainage 
is  necessary. 

Contra-indications. — When  the  condition  causes  little 
pain,  and  attacks  of  colic  are  infrequent,  no  operation  is 
necessary.  In  frequent  slight  attacks,  associated  with 
jaundice,  and  the  successive  passage  of  several  small  stones, 
it  is  well  to  temporize,  particularly  if  the  patient  is  free  from 
pain  between  attacks.  The  presence  of  ascites  contra- 
indicates  operation  for  gall-stone  disease,  as  also  diabetes, 
extreme  obesity,  advanced  arteriosclerosis,  and  cardiac  or 
serious  pulmonary  disease.  Advanced  age  is  not  an  absolute 
contra-indication.  Acute  obstruction  of  the  common  duct 
(see  under  diagnosis)  may  terminate  after  several  weeks  in 
recovery,  and,  therefore,  one  should  wait  in  such  cases. 
Intense  jaundice  of  some  months'  duration,  with  or  without 
haemorrhage  from  mucous  membranes,  contra-indicates 
operation  on  account  of  the  great  risks  of  serious  parenchy- 
matous hcemorrhage,  particularly  in  old  people.  Advanced 
cancer  of  the  biliary  passages  forbids  operation  ;  several 
cases  of  my  own,  with  only  moderate  infiltration  of  the  liver 
around,  have  died  the  day  after  operation. 

Risks  of  operation. — The  mortality  varies  much  according 
to  what  operation  is  necessary.  Kehr's  mortality  in  720 
cases  is  15-5  per  cent.  The  least  dangerous  are  the  con- 
servative operations  :  cystostomy,  cysticotomy,  cystendysis, 
with  2  per  cent,  then  extirpation  of  the  gall-bladder,  with 
3  per  cent.  Choledochotomy  was  attended  by  a  6-5  per 
cent  mortality  in  137  cases.  Among  cases  in  which 
operations  had  to  be  done  at  the  same  time  on  other  organs 
(stomach,  intestine,  pancreas,  etc.),  or  in  which  there  was 
some  serious  complication,  the  proportion  of  deaths  was 
very  high :  ninety-three  in  191  operations.  Mortality  is 
specially  high  when  carcinoma  or  diffuse  cholangitis 
complicates  the  disease. 

In  many  cases  an  exact  diagnosis  is  impossible,  and  one 
is  often  unable  to  foretell  the  risk  of  operation  because, 
until  the  abdomen  is  opened,  it  is  not  certain  what  particular 
operative  procedure  will  have  to  be  undertaken. 

Sometimes  biliary  fistulae  persist  for  a  long  time,  but 
they  almost  always  heal  eventually.  Operation  has 
sometimes  to  be  repeated  for  stones  left  behind,  or  for 
adhesions,  causing  kinking  of  the  cystic  duct,  and  profuse 


3i6  INDICATIONS    FOR    OPERATION    IN 

mucous  secretion.  Recurrent  haemorrhage  may  call  for  a 
second  operation,  and  sometimes  torsion  of  the  pylorus 
and  duodenum  makes  it  necessary  to  reopen  the  wound. 
Ventral  hernia  is  common. 

When  choledochotomy  with  hepatic  duct  drainage  is 
the  operation  done,  Kehr  mentions  three  comparatively 
common  complications  :  (a)  pneumonia  in  8  per  cent  of 
cases  ;  (6)  acute  dilatation  of  the  stomach,  with  vomiting, 
and  sometimes  diarrhoea  (lesions  of  the  mesenteric  arteries), 
(c)  haemorrhage  into  the  stomach  and  intestine,  and 
hsematemesis,  which  can  sometimes  be  checked  by  washing 
out  the  stomach  and  other  treatment. 

Prognosis. — Results  of  operation. — In  very  many  cases 
opening  the  gall-bladder  and  removal  of  the  stones  result 
in  complete  and  permanent  recovery.  Even  after  long- 
continued  high  fever  from  a  severe  infection  of  the  biliary 
passages,  complete  restoration  to  health  may  follow  opera- 
tion. In  one  such  case  under  my  care  high  fever  had 
been  present  for  some  weeks,  and  severe  septic  absorption  ; 
pus  was  found  in  the  gall-bladder  and  came  freely  from 
the  cystic  duct ;  the  patient  recovered  completely  (of  course 
after  a  long  illness),  after  the  removal  of  a  large  number 
of  calculi  from  the  gall-bladder,  and  the  spontaneous 
discharge  of  others.  Still  better  are  the  results  of  total 
extirpation  of  the  gall-bladder  and  drainage  of  the  common 
duct.  When  this  operation  is  done  it  is  rare  for  stones  to 
be  overlooked  and  cause  subsequent  trouble. 

The  possibility  of  a  true  re-formation  of  calculi  after 
operation  is  admitted  by  all  authors,  but  such  an  event  is 
rare.  Stones  left  behind  will,  of  course,  cause  trouble 
later.  Sometimes  they  form  round  silk  sutures  left  in  the 
bladder.  Almost  always  recurrence  of  symptoms  is  due  to 
stones  overlooked,  and  although  this  happens  from  time  to 
time,  it  is  of  no  importance  as  an  argument  against  surgical 
treatment  when  the  indications  are  clear  ;  defective  tech- 
nique, or  the  difficulties  of  the  operation,  are  responsible 
for  the  accident ;  it  is  well  to  bear  in  mind  the  possibility 
of  its  occurrence  when  stating  the  prospects  of  the  operation 
to  the  patient.  Other  troublesome  eventualities  may 
follow  operation,  in  particular,  the  development  of  adhesions, 
which,  as  in  one  of  my  cases,  may  make  the  last  state  of  the 
patient  worse  than  the  first.     In  many  of  my  cases  operation 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     3U 

has  given  perfect  results  ;  occasionally  stones  overlooked 
have  necessitated  a  second  operation,  but  all  such  cases 
have  recovered. 

Without  operation. — In  most  cases  gall-stones  do  not 
lead  to  any  condition  threatening  life,  and  in  this  respect 
the  prognosis  is  relatively  good.  It  is  necessary  to  insist 
on  this  fact,  because  several  authors  have  written  of  the 
condition  as  if  it  usually  produced  serious  lesions,  and  have 
expressed  in  consequence  much  too  comprehensive  a  view 
of  the  necessity  for  operation.  According  to  my  own 
experience,  and  that  of  several  other  clinicians,  expectant 
treatment  gives  a  very  low  mortality :  about  4  to  5  per  cent. 
Other  writers,  on  the  basis  usually  of  a  relatively  small 
material,  take  a  more  serious  view,  thus  Binder  in  96  cases, 
52  of  which  were  kept  under  observation  for  a  long  time, 
recorded  eleven  deaths.  The  most  serious  complications 
and  eventualities  have  been  noted  above.  Carcinoma  of  the 
gall-bladder  is  one  of  the  possible  results  of  gall-stone  disease 
not  operated  on.  Unfortunately  this  occurs  just  in  those 
cases  in  which  the  calculi  have  given  rise  to  no  symptoms. 

The  onset  of  complications  (suppuration,  long-continued 
jaundice,  peritonitis,  and  perforation)  increases  the  gravity 
of  the  prognosis.  Although  the  affection  rarely  ends  in 
recovery  without  operation,  there  is  no  doubt  that,  in  many 
cases,  except  those  presenting  urgent  symptoms,  the  regu- 
lation of  diet,  and  treatment  with  mineral  waters,  is  able  to 
produce  a  latency  of  symptoms  satisfactory  to  the  patient 
and  his  medical  attendant. 

LITERATURE. 

Kehr.  Cholelithiasis.  Handbuch  der  prakt.  Chir.  v.  Bergmann, 
Mikulicz,  u.  Bruns.     2nd  Ed.     Bd.  iii. 

KoRTE.  Indikat.  z.  chir.  Behandlung  der  Cholelithiasis  u.  Chole- 
cystitis.    Deut.  med.  Wochens.,  1903,  No.  15. 

Fink.  Erfolge  der  Karlsbader  Kur  u.  d.  Chir.  Behandlung  d. 
Gallensteinleidens.      1903. 

RiEDEL.  Die  Pathogenese,  Diagnose,  u.  Behandlung  d.  Gallen- 
steinleidens.    G.  Fischer.     1903. 

Langenbuch.  Chirurgie  der  Leber  u.  d.  Gallenblase.  Deut. 
Chir.,  Stuttgart,   1898. 

Naunyn.     Klinik  der  Cholelithiasis.     Leipzig.      1892. 

Quincke  u.  Hoppe-Seyler.  Krankheiten  der  Leber.  Noth- 
nagel's  Handbuch  d.  spez.  Pathol,  u.  Therap.,  Wien,  1899. 

Lejars.  Contribution  a  I'Etude  des  Indications  de  la  Chole- 
cystotomie.     Rev.  de  Chir.,  1896,  No.  9. 


3i8  INDICATIONS    FOR    OPERATION    IN 

Naunyn.  Ueber  die  Vorgange  bei  der  Cholelithiasis,  welche 
die  Indikat.  z.  Operat.  entschieden.  Mitteil.  a.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     Bd.  iv. 

Herrmann.  Beitrage  zur  Frage  :  1st  die  Cholelithiasis  intern 
Oder  chirurgisch  zu  behandlung  ?     Ibidem. 

LoBKER.     Ibidem. 

Merk.     Beitr.  z.  Path.  u.  Chir.  der  Gallensteine.     Ibidem.     Bd.  ix. 

Petersen.    Gallensteinkrankheit.    Bruns'.  Beitr.    Bd.  xxiii.    H.  3. 

Jeannel.  Contribution  au  Traitement  Chirurgicale  de  la  Lithiase 
Biliaire.     Arch.  Prov.  d.  Chir.,  1896,  No.  9. 

Vautrin.  De  FObstruction  Calculaire  du  Choledoch.  Rev.  de 
Chir.,  T.  xvi.,  p.  446. 

Mayo.  Some  Observations  on  the  Surgery  of  the  Gail-Bladder. 
Annals  of  Surgery,  Oct.  1899. 

Richardson.  The  Indications  for  Extirpation  of  the  Gall-Bladder. 
Med.  News,  May,  1903. 

Murphy.     The  Diagnosis  of  Gail-Stones.     Ibidem. 

Mayo.  Operations  on  the  Gall-Bladder  and  Ducts.  Boston 
Med.  and  Surg.  Jour.,  May  21,  1903. 

F.  A.  Berg.  The  Indications  for  the  Surgical  Treatment  of 
Cholelithiasis.     Med.  Record,  No.   18,   1902. 

MiLHiET.  De  la  Cholecystectomie  dans  la  Lithiase  Biliaire. 
These  de  Paris.     1902. 

Terrier  et  Auvray.  Chir.  du  Foie  et  des  Voies  Biliaires.  Paris, 
1 901.     Felix  Alcan. 

Pauchet.  Chirurgie  des  Voies  Biliaires.  Paris,  1900.  Bailliere 
et  Fils. 

MoYNiHAN.     Gall-Stones  and  their  Surgical  Treatment.      1905. 


CHOLELITHIASIS   (ASSOCIATED   CONDITIONS). 

(A.)       HYDROPS     OF    THE     GALL-BLADDER. 

Etiology. — This  condition  is  .caused  by  obstruction  of 
the  cystic  duct  by  stone,  scar,  or  kinking.  Often  also  it  is 
present  as  a  comphcation  when  a  mahgnant  tumour  involves 
and  compresses  the  cystic  or  common  duct. 

Pathological  Anatomy. — The  gall-bladder  is  often 
enormously  dilated,  and  the  wall  much  thinned  in  parts  ; 
it  is  filled  with  a  colourless  ropy  fluid. 

Clinical  Course. — Hydrops  of  the  gall-bladder  is  only  a 
complication  of  other  morbid  processes.  A  spherical  or 
pyriform  swelling  presents  below  the  lower  border  of  the 
liver,  it  moves  with  respiration,  and  often  can  be  displaced 
with  the  hand,  but  returns  to  its  original  situation.  It  is 
not  tender  to  pressure,  in  consistence  it  is  elastic,  but 
fluctuation   cannot,   as   a  rule,   be   made   out.     When   the 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     319 

primary  cause  is  a  malignant  growth,  ascites  and  jaundice 
may  be  present.  When  the  gall-bladder  is  enormously 
distended  it  is  liable  to  be  confused  with  other  cystic 
abdominal  tumours.  Ovarian  cysts  are  distinguished  by 
their  pelvic  origin  and  attachments  ;  a  hydronephrotic 
kidney  comes  forward  from  the  loin,  and  is  liable  to  sudden 
variations  in  size.  A  pedunculated  hydatid  cyst  of  the 
liver  is  difficult  to  distinguish  from  a  distended  gall-bladder 
except  by  its  slow  growth.  A  movable  kidney  presents  the 
characteristic  renal  outline,  and  can  be  replaced  in  the  loin. 
I  am  aware  of  a  case  of  distended  and  very  movable  gall- 
bladder which  was  mistaken  by  several  observers  for  a 
hydronephrotic  and  mobile  kidney,  the  true  nature  of  the 
condition  being  only  discovered  at  operation. 

INDICATIONS   FOR   OPERATION. 

A  distended  gall-bladder  which  is  not  due  to  inflammatory 
causes  only  calls  for  operation  when  the  distension  develops 
rapidly  and  threatens  rupture,  or  when  it  interferes  by 
pressure  with  the  functions  of  neighbouring  organs,  and 
causes  serious  symptoms,  such  as  repeated  vomiting,  a 
troublesome  sense  of  fullness,  and  intestinal  disturbance. 
When  operation  is  necessary  the  abdomen  is  opened,  and 
a  fistula  is  established  ;  puncture  without  opening  the 
abdomen  is  unjustifiable,  on  account  of  the  risks  of  leakage. 

Contra-indications. — When  the  condition  which  causes  the 
distension  is  irremediable  by  operation  (new  growth  about 
the  hilum  of  the  liver),  and  when  the  distension  itself  is  not 
extreme,  no  operation  should  be  done.  Extreme  age, 
arteriosclerosis,  old-standing  jaundice,  with  haemorrhage 
from  the  mucous  membranes,  constitute  contra-indications. 

//  no  operation  is  undertaken,  and  the  distension  increases 
rapidly,  the  gall-bladder  may  rupture  and  fatal  peritonitis 
follow  ;  but  this  accident  is  rare.  As  a  rule,  the  condition 
is  of  small  importance  compared  with  the  primary  affection 
which  causes  it. 

LITERATURE. 

Martin.  Diagnostik  der  Bauchgeschwiilste.  Deut.  Chir.  Stutt- 
gart:   F.  Enke,  1903. 

Machard.  Des  Dilatations  et  Ruptures  Spontanees  de  la 
Vesicule  Biliaire.     Arch.  Gener.  des  Med.,  1900. 

See  also  Quincke,  Langcnbuch,  Terrier  ct  Auvray,  above. 


320  INDICATIONS    FOR    OPERATION    IN 

(B.)     CHOLECYSTITIS : 
EMPYEMA    OF    THE    GALL-BLADDER. 

Etiology. — Inflammation  of  the  gall-bladder  is  caused 
by  the  invasion  of  micro-organisms.  It  is  often  consecutive 
to  some  general  infective  disease,  particularly  enteric  fever, 
pneumonia,  dysentery,  and  pyaemia.  Other  common  causes 
are  calculi,  foreign  bodies  (intestinal  worms),  and  any 
condition  which  causes  constriction  of  the  bile-ducts. 

Pathological  Anatomy. — -Cholecystitis  is  usually  associ- 
ated with  cholangitis.  When  the  condition  is  recent,  the 
gall-bladder  is  usually  dilated  ;  when  it  is  of  old  standing 
the  bladder  is  often  shrunken.  The  bladder  contains  either 
a  mixture  of  bile  and  mucus,  or  pus.  When  the  wall 
ulcerates,  perforation  not  uncommonly  follows  ;  usually  in 
such  cases  there  are  adhesions  around,  and  perforation 
occurs  into  a  preformed  localized  cavity ;  under  such 
circumstances  a  vesico-intestinal  fistula  may  be  established 
later. 

Clinical  Course. — Tenderness  on  pressure  and  enlarge- 
ment of  the  gall-bladder  are  the  cardinal  symptoms  of 
cholecystitis.  There  is  also  subjective  pain  ;  the  tenderness 
is  particularly  noted  when  pressure  is  made  over  the  gall- 
bladder on  deep  inspiration.  The  distended  gall-bladder 
is  often  distinctly  pyriform  in  shape,  but  adhesions  to  the 
omentum  may  render  its  outline  quite  indistinct ;  often  it 
may  be  made  out  to  move  with  respiration,  but  not  always. 
There  is  frequently  either  continuous  or  remittent  fever, 
and  sometimes  it  is  definitely  intermittent.  When  the 
cholecystitis  is  of  a  severe  type,  vomiting,  meteorism,  and 
temporary  intestinal  paresis  are  often  present,  and  there  is 
much  general  disturbance.  When  jaundice  supervenes  it 
is  evidence  of  cholangitis,  and  its  intensity  will  vary  with 
the  extent  of  the  latter. 

Diagnosis  and  Differential  Diagnosis. — If  the  cardinal 
symptoms  are  present,  if  there  is  a  history  pointing  to 
cholelithiasis,  or  if  the  symptoms  develop  in  the  course  of 
an  attack  of  typhoid  fever,  the  diagnosis  presents  no 
difficulties. 

Perforation  may  often  be  recognized  by  a  sudden  aggrava- 
tion of  pain,  accompanied  by  vomiting,  increased  pulse-rate, 
low  temperature,  and  collapse.    In  most  cases  the  abdominal 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     321 

walls  are  intensely  rigid,  and  palpation  impossible.  Free 
fluid  in  the  peritoneal  cavity  can  often  be  made  out  a  few 
hours  after  perforation. 

The  condition  is  to  be  distinguished  from  appendicitis,  in 
which  the  local  signs  are  prominent  in  the  right  iliac  fossa, 
and  there  is  an  absence  of  history  pointing  to  gall-stones  ; 
from  renal  colic,  in  which  there  is  tenesmus,  blood  in  the 
urine  and  oliguria;  from  chronic  perforation  of  gastric  ulcer 
by  an  absence  of  any  history  of  hsematemesis,  and  by  the 
immobility  of  any  tumour  that  is  present  ;  and  from 
intestinal  tumour  and  faecal  obstruction  by  the  history, 
the  absence  of  any  marked  tenderness  on  pressure, 
and  the  presence  of  exaggerated  peristalsis  in  these 
conditions. 

INDICATIONS   FOR  OPERATION. 

The  gall-bladder  must  always  be  opened  whenever  there 
are  signs  of  the  presence  of  pus.  Operation  is  especially 
urgent  when  the  gall-bladder  rapidly  distends  and  is  very 
tender  to  pressure,  when  there  are  fever,  rigors,  and  marked 
leucocytosis,  and  especially  if  such  a  condition  occurs  after 
typhoid,  because  perforation  is  particularly  liable  to  occur 
in  typhoid  infections.  Operation  must,  of  course,  be  done 
at  once  when  there  is  reason  to  believe  that  perforation  has 
occurred.  When  the  physical  signs  point  to  non-purulent 
cholecystitis  associated  with  cholelithiasis,  the  indications 
for  surgical  intervention  follow  the  same  rules  as  those 
already  given  for  gall-stone  disease. 

Contra-indications. — -The  rules  for  operation  in  cases  of 
acute  perforation  are  those  which  are  followed  in  all  cases 
of  perforation  of  hollow  viscera  ;  when  the  patient  is  in 
extremis  from  diffuse  peritonitis,  operation  will  only  hasten 
death  from  shock.  Opening  of  the  gall-bladder  is  contra- 
indicated  when  the  cholecystitis  is  only  part  of  a  general 
pyaemic  infection,  or  if  it  is  due  to  carcinoma  involving  the 
bile-ducts. 

Unless  operation  is  required  to  save  life,  as  in  acute 
perforation,  it  will  not  be  recommended  to  patients  the 
subjects  of  diabetes,  arteriosclerosis,  and  other  serious 
organic  disease. 

Prognosis. — Risks  and  results  of  operation. — In  most 
cases  operation  results  in  complete  recovery.     Death  occurs 


322  INDICATIONS    FOR    OPERATION    IN 

in  some  cases  from  shock,  in  others  it  is  due  to  concurrent 
disease.  Only  rarely  is  there  any  trouble  from  persistent 
biliary  fistula. 

A  case  under  my  care  was  that  of  a  young  woman  about 
twenty  years  of  age.  Agonizing  pain  in  the  region  of  the 
gall-bladder  supervened  after  several  days  of  fever  with 
rigors,  and  I  felt  in  this  situation  an  ill-defined  swelling. 
The  temperature  was  high,  the  pulse  rapid,  there  was 
jaundice  and  a  coated  tongue,  and  free  fluid  was  present  in 
the  peritoneal  cavity.  The  diagnosis  was  cholecystitis  and 
perforation.  At  the  operation  there  was  found  to  be 
tubercular  peritonitis,  with  adhesions  between  the  omentum 
and  liver.  The  patient  died  next  day,  and  behind  the 
adherent  omentum  a  perforated  empyema  of  the  gall- 
bladder was  found. 

//  no  operation  is  undertaken,  there  is  risk  of  general 
peritonitis,  either  by  propagation,  by  contiguity,  or  through 
the  medium  of  a  perforation.  Empyema  may  end  in 
septicsemia.  When  the  inflammatory  process  extends 
outside  the  gall-bladder  to  neighbouring  structures,  dense 
adhesions  tend  to  form,  and  sometimes  there  are  established 
flstulse  between  the  gall-bladder  and  the  intestine,  or  the 
exterior. 

LITERATURE. 

QuiNXKE.  Erkrankungen  der  Leber  u.  Gallenblase.  Nothnagel's 
Handbuch  d.  spez.  Path.     Bd.  xviii.      1899. 

DuNGERN.  Cholecystitis  Typhosa.  Miinch.  med.  Wochens.,  No. 
26,  1897. 

Hawkins.  On  Jaundice  and  on  Perforation  of  the  Gall-Bladder 
in  Typhoid    Fever.      ]\Iedico-Chir.  Transactions.     Bd.  Ixxx.      1897. 

Langenbuch.     Chirurgie  der  Leber  u.  Gallenblase,  2nd  Part,  1 897. 

Pruszynski.  Pathogenese  der  Erkrankungen  der  Gallenwege. 
Wien.  klin.  Wochens.,  No.    11,   1904. 

W.  Thompson.  Cholelithiasis,  Cholecystitis.  New  York  JNIed. 
Journ.,  April  19,   1892. 

Terrier  et  Auvray.     Chir.  d.  Foie.     Paris,  1901. 


(C.)    INTESTINAL^OBSTRUCTION  BY  GALL-STONE. 

Pathological  Anatomy. — Gall  -  stones  which  cause 
obstruction  find  their  way  into  the  intestine  through  fistulae, 
usually  into  the  duodenum  (28  in  30  cases  examined  post 
mortem),  rarely  into  the  colon.     The  stone  usually  becomes 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     .^23 

impacted  in  the  region  of  the  ileocaecal  valve,  next  in 
frequency  in  the  duodenum  and  jejunum.  Obstruction 
occurs  the  more  easily  if  there  is  already  some  narrowing  of 
the  intestine  due  to  other  causes  ;  sometimes  there  are  signs 
of  a  local  peritonitis  at  the  seat  of  impaction ;  in  other  cases 
a  local  spasmodic  contraction  of  the  gut  appears  to  have 
determined  the  seat  of  the  obstruction. 

Clinical  Course. — As  a  rule,  the  attack  of  obstruction  is 
immediately  associated  with  a  previous  attack  of  biliary 
colic.  Often  there  is  a  typical  history  of  cholelithiasis,  and 
signs  also  of  definite  localized  peritonitis  around  the  gall- 
bladder preceding  the  appearance  of  the  symptoms  of 
obstruction.  When  the  seat  of  impaction  is  in  the  upper 
part  of  the  digestive  tract,  stomach  symptoms  predominate  : 
frequent  bilious  vomiting,  rapid  development  of  gastric  dila- 
tation, marked  wasting,  absence  of  meteorism,  but,  as  a  rule, 
obstruction  to  faeces  and  flatus,  with  a  retracted  abdomen. 
When  the  seat  of  obstruction  is  lower,  pain  is  the  first  symp- 
tom, tenderness  to  pressure  is  only  slight,  and  develops  later, 
vomiting  occurs  early  and  soon  becomes  fsecal,  complete 
obstruction  is  soon  established,  but,  according  to  Naunyn, 
sometimes  flatus  fcan  pass.  Sometimes  the  calculus  is 
palpable,  and  the  patient,  or  his  medical  attendant,  may  be 
able  to  make  out  its  onward  passage.  If  the  calculus  is 
arrested  in  the  large  bowel  there  is  gaseous  distension  in 
the  flanks,  vomiting  and  collapse  are  delayed,  and  the 
phenomena  of  intestinal  obstruction  are  often  remarkably 
intermittent.  If  peritonitis  supervenes  the  pulse-rate  rises, 
pyrexia  appears,  the  tongue  becomes  coated,  meteorism 
becomes  extreme,  and  there  are  signs  of  free  fluid  in  the 
peritoneal  cavity. 

The  Diagnosis  is  clear  when  obstruction  occurs  in  a 
patient  known  to  have  gall-stones,  and  immediately  following 
a  definite  attack  of  colic.  If  the  seat  of  obstruction  is  in 
the  small  intestine,  the  stone  may  sometimes  be  palpated,  and 
its  arrest  at  the  ileocaecal  junction  be  made  out.  Of  special 
significance  in  diagnosis  is  the  presence  of  obstruction  of 
an  intermittent  type,  and  the  passage  of  flatus  while  the 
fiecal  obstruction  is  complete  and  the  vomited  matter  is 
f cecal.  At  the  end  of  an  attack  the  calculus  may  be  found 
in  the  rectum. 


324  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS   FOR  OPERATION. 

Naunyn  considers  that  operation  may  generally  be 
avoided  in  view  of  the  relatively  slight  degree  of  obstruction 
symptoms  and  the  fluctuating  course  of  the  condition.  It 
is  specially  necessary  to  operate  when  the  stone  is  lodged 
in  the  neighbourhood  of  the  ileocaecal  valve.  Other 
writers,  particularly  surgeons,  hold  different  view^s. 

Considering  the  difficulties  in  diagnosis,  and  the  possi- 
bilities of  mistake,  it  is  well  to  follow  the  course  of  treatment 
recommended  by  Korte.  He  advises  first  the  administra- 
tion of  opium,  with  stomach  lavage  and  enemata  ;  if  at  the 
end  of  a  period  not  longer  than  forty-eight  hours  the  vomiting 
has  not  stopped,  and  the  abdominal  pain  and  distension 
persist,  then  operation  should  be  'proceeded  with.  The 
abdomen  is  opened,  and  the  intestine  is  incised  ;  occasionally 
this  may  be  done  under  local  anaesthesia. 

Contra-indications. — If  peritonitis  is  established,  and  the 
patient's  strength  already  much  exhausted,  it  will  usually 
be  wise  to  abstain  from  operation.  As  above  stated,  it  is 
well  in  most  cases  to  allow  a  period  of  forty-eight  hours  to 
elapse  before  operation,  when  there  are  sufficient  grounds 
for  believing  that  the  obstruction  is  due  to  a  gall-stone. 

Prognosis. — Dangers  and  results  of  operation.  If  only 
the  worst  cases  are  operated  on,  the  mortality  is  very  high  ; 
but,  since  1891,  earlier  operations  have  been  generally 
undertaken.  In  34  cases  operated  on  between  1891  and 
'1900  recovery  followed  in  more  than  50  per  cent.  The 
percentage  of  recoveries  in  the  operated  and  not-operated 
cases  cannot  be  compared,  because  it  is  the  slight  cases 
that  are  treated  by  expectant  methods,  and  those  which 
are  operated  on  would  probably  have  gone  to  swell  the 
fatalities  without  it. 

The  causes  of  death  are  exhaustion  and  peritonitis, 
occurring  most  frequently  when  operation  is  done  at  a  late 
stage. 

Without  operation. — Schiiller  gives  44  per  cent  recoveries 
in  150  cases  ;  Courvoisier,  56  per  cent  in  125  cases  ; 
Kirmisson  and  A.  Borchard  record  a  70  per  cent  mortality 
in  105  cases.  In  cases  where  the  stone  is  passed  death 
may  foUow  from  intestinal  ulceration  and  diarrhoea,  or 
perforation  ;  the  consequences  of  ulceration  may  give 
rise  to  troublesome  symptoms. 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     325 

LITERATURE. 

HcNiGMANN.  Ueber  Gallenstein-Ileus.  Centralb.  f.  d.  Grenzge- 
biete  d.  Med.  u.  Chir.      1900. 

Garin.  Contribution  a  I'Etude  des  Complications  de  la  Lithiase 
Biliaire  (Occlusion  Intestinale).     These  de  Paris.      1897. 

KiRMissoN  et  BoRCHARD.  De  rOcclusion  Intestinale  par 
Calculs  Biliaires.     Arch.  Gener.  de  Med.,   1892. 

KoRTE.  Ueber  den  Darmverschluss  durch  Gallensteine.  Arch. 
f.  klin.  Chir.  Bd.  xlvi.  p.  321  ;  and  Deut.  med.  Wochens.  1894. 
p.  171. 

Naunyn.  Ileus.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
Bd.  i. 

Rehn.     Gallenstein-Ileus.     Arch.  f.  klin.  Chir.,  Ix. 

Bradbury.  Two  Cases  of  Obstruction  of  the  Small  Intestine  by 
Gail-Stones.     Brit.  Med.  Jour.,   1897,  p.  796. 

NoTHNAGEL.  Erkrankungcn  des  Darmes.  Obturation  durch 
Gallensteine.     2nd  Ed.,  p.  375.      1903. 


CARCINOMA  OF  THE  GALL-BLADDER. 

Etiology. — Carcinoma  of  the  gall-bladder  is  often 
associated  with  the  presence  of  gall-stones  in  individuals 
above  the  age  of  forty. 

Pathological  Anatomy. — Carcinoma  may  develop  in 
any  part  of  the  gall-bladder,  and  tends  to  extend  early  to 
the  liver  either  as  a  diffuse  infiltration  or  in  the  form  of 
secondary  circumscribed  nodules.  The  cystic  duct  becomes 
involved  as  the  disease  advances.  Lymphatic  glands  in 
the  portal  fissure  are  often  involved  early  and  encroach  on 
the  common  and  hepatic  ducts.  The  growth  is  usually  of 
the  "  scirrhous  "  type. 

Clinical  Course. — In  many  cases  the  disease  in  its  early 
stages  gives  rise  to  no  symptoms,  the  latter  making  their 
appearance  first  when  the  liver  is  involved.  Localized 
subjective  pain  is  an  early  sign,  and  associated  with  it  a 
tender,  firm  gall-bladder  tumour  niay  be  made  out ;  hydrops 
of  the  gall-bladder  is  not  uncommon.  In  the  earlier  stages 
at  any  rate  the  tumour  moves  with  respiration.  Jaundice 
and  emaciation  make  their  appearance  later  and  become 
gradually  more  marked.  The  observations  of  many 
writers,  which  my  own  confirm,  go  to  show  that  the  progress 
of  the  disease  is  usually  extremely  rapid,  and  from  the 
appearance  of  the  first  symptoms  lasts  only  from  a  few 
weeks  to  a  few  months. 


326  INDICATIONS    FOR    OPERATION    IN 

Diagnosis. — ^When  there  is  present  in  the  region  of  the 
gall-bladder  a  hard  nodular  tumour  which  has  the  general 
configuration  of  the  gall-bladder  and  moves  with  respiration, 
there  can  be  little  doubt  as  to  its  character  ;  the  later  signs 
of  infiltration  of  the  edge  of  the  liver,  jaundice,  ascites,  and 
enlargement  of  the  liver,  confirm  the  diagnosis.  The 
persistence  of  jaundice  associated  with  a  bladder  tumour  is 
in  favour  of  cancer  and  against  calculus.  The  discovery 
of  enlarged  hard  glands  in  the  neck  or  elsewhere  may  aid 
in  diagnosis.  Tumours  of  the  pylorus  are  sometimes  only 
with  difficulty  distinguished  from  gall-bladder  tumours. 
X-ray  examination  with  the  aid  of  a  shot-loaded  catheter 
may  be  of  assistance,  but  more  important  is  the  examination 
of  the  stomach  contents  as  to  the  presence  of  hydrochloric 
acid,  and  the  length  of  time  they  are  retained  ;  a  digestive 
leucocytosis  is  absent  in  stomach  cancer. 

INDICATIONS   FOR   OPERATION. 

It  is  only  in  early  cases  that  operation  can  promise 
good  results.  Unfortunately,  the  disease  is  not  usually 
discovered  in  its  early  stage ;  occasionally  it  has  been 
found  in  the  course  of  a  gall-stone  operation  or  some 
other  abdominal  operation.  Cholecystectomy,  with  re- 
moval of  adjacent  liver  tissue,  is  only  permissible  when 
the  disease  is  confined  to  narrow  limits,  when  the  liver 
is  not  yet  invaded  or  only  to  a  very  slight  degree,  and 
when  there  are  no  metastases. 

Contra-indications.  —  A  large  hard  tumour  in  the  gall- 
bladder region,  signs  of  liver  infiltration,  metastases, 
cachexia,  ascites,  and  intense  jaundice,  all  contra-indicate 
operation.  It  is  obvious  from  what  has  already  been  said 
that  the  signs  of  the  disease  when  discovered  are  usually 
sufficient  to  contra-indicate  operation. 

Prognosis. — Results  of  operation. — In  sixteen  cases 
collected  by  Laspeyres,  eight  months  after  operation  only 
one  showed  no  signs  of  recurrence,  eight  had  died  from 
recurrence  or  metastases,  three  from  sepsis  and  peritonitis. 
As  matters  at  present  stand  in  regard  to  diagnosis,  the 
prognosis  of  operation  is  bad.  In  my  opinion,  the  chances 
of  success  are  such  that  proposals  to  operate  for  gall-bladder 
cancer  should  be  resisted. 


DISEASES  OF  GALL-BLADDER  AND  BILE-DUCTS.     327 

LITERATURE. 

Laspeyres.  Das  Carcinom  der  Gallenblase.  Centralb.  f.  d. 
Grenzgebiete  d.  Med.  u.  Chir.,  1901. 

RoBSON.  Partial  Hepatectomy  for  Primary  Cancer  of  the  Liyer. 
Brit.  Med.  Jour.,  Oct.  29,  1898.  ' 

RoLLESTON.  Malignant  Disease  of  the  Gail-Bladder.  Clin. 
Journ.     April  7th,   1897. 

Heidenhain.  Carcinom  der  Gallenblase.  Deut.  Zeit.  f.  Chir. 
Bd.  xlyii. 

Hollander.  Totalexstirpation  der  Gallenblase  wegen  Carcinom. 
Deut.  med.  Wochens.,  No.  26,    1898. 

DuRET.  Tumeurs  Operables  de  la  Vesicule  Biliaire.  Rev.  de 
Chir.,  No.  11,  1898. 

Terrier  et  AuyRAV.     Rev.  de  Chir.,  Feb.  and  March,   1900. 

De  Saint  Fuscien.  Cancer  Primitif  de  la  Vesicule  Biliaire. 
These  de  Paris,   1897. 


CHAPTER     XIX. 
Diseases    of    the    Liver. 


331 


Chapter   XIX. 
DISEASES    OF    THE    LIVER. 

TUMOURS    OF    THE    LIVER. 

Etiology. — Many  types  of  liver  new  growth  are  con- 
genital, others  are  metastatic,  others  primary.  Traumata 
are  often  etiologically  important.  Syphilis  may  give  rise 
to  tumours  of  large  size. 

Pathological  Anatomy. — These  tumours  are  benign 
or  malignant.  The  benign  tumours  may  be  cystic  and 
either  solitary  or  multiple,  and  if  the  latter,  there  may  be 
•similar  cystic  growths  in  other  abdominal  organs.  The 
more  common  benign  solid  tumours  are  fibromata,  adeno- 
mata, angiomata,  and  syphilomata ;  these  are  usually  solitary 
and  sharply  defined.  The  malignant  growths  are  primary 
and  secondary  carcinomata  and  sarcomata.  Primary  car- 
cinoma usually  takes  the  form  of  a  solitary  tumour  occupying 
one  lobe  and  often  causing  great  enlargement,  but  primary 
-cancer  may  also  be  diffuse.  The  secondary  cancerous 
growths  are  much  more  common  than  the  primary. 

Clinical  Course. — The  non-parasitic  cysts  exhibit  the 
same  signs  and  symptoms  as  the  hydatid  cysts  {vide  infra). 
Benign  liver  tumours  grow  slowly  and  are  not  infrequently 
pedunculated.  They  are  often  tender  to  pressure,  and  cause 
gastric  disturbance,  and  abdominal  pain  of  a  sharp,  shooting 
character.  The  malignant  tumours  may  be  buried  in  the 
substance  of  the  liver,  or  present  as  nodular  growths  on  the 
surface.  The  bile-ducts  and  the  portal  vein  may  be  com- 
pressed, with  resulting  jaundice  and  ascites.  Cachexia  is 
not  uncommonly  present  in  the  early  stages ;  metastases  are 
to  be  expected  in  the  peritoneum,  lungs,  and  pleura.  Syphilis 
often  causes  diffuse  enlargement  of  the  liver,  and  later,  a 
coarse  cirrhosis  or  large  gummatous  tumours  may  be  formed 
wiiich  yield  to  sj^ecific  treatment. 


332  INDICATIONS    FOR    OPERATION    IN 

Diagnosis. — In  enlargement  of  the  liver,  either  dilfuse 
or  circumscribed,  the  history  must  be  enquired  into  for 
syphilis  ;  the  effect  of  antisyphilitic  treatment  and  coarse 
cirrhotic  intersection  indicates  the  diagnosis.  Gradual 
growth,  fluctuation,  and  the  examination  of  fluid  obtained 
by  exploratory  puncture,  will  point  to  hydatid  cyst. 
Exploratory  puncture  is  not  without  risk.  Chronic  abscess 
is  associated  with  more  or  less  fever,  and  has  a  different 
history.  Cystic  liver  is  a  very  chronic  process  and  usually 
painless.  Diffuse  carcinoma  of  the  liver,  which  is  of  no 
surgical  interest,  may  be  with  difficulty  distinguished  from 
amyloid  disease,  hypertrophic  cirrhosis,  and  other  conditions 
in  which  the  liver  is  much  enlarged. 

INDICATIONS   FOR   OPERATION. 

Operation  is  but  rarely  indicated  for  liver  tumours.  If 
there  is  present  a  definite  pedunculated  tumour  causing 
troublesome  symptoms,  and  if  there  are  no  indications  of 
its  being  metastatic  in  character,  an  exploratory  laparotomy 
is  justifiable  for  the  purpose  of  removing  the  growth  if  the 
local  conditions  are  favourable. 

Contra-indicaiions. — Signs  of  syphilis  contra-indicate 
operation  until  antisyphilitic  remedies  have  been  given  a 
prolonged  trial.  Bilateral  cystic  kidneys  associated  with 
signs  of  cystic  disease  of  the  liver  contra-indicate  operation. 
No  operation  will  be  done  when  there  is  reason  to  believe 
that  the  growth  is  metastatic,  when  there  are  multiple 
growths,  when  there  is  serious  circulatory  disturbance  or 
atheroma,  or  when  the  patient  is  of  advanced  age. 

In  one  of  my  cases  (a  man  about  forty-five  years  of  age) 
nodes  could  be  felt  on  the  upper  surface  of  the  liver.  One 
day  a  large  amount  of  reddish  pus,  containing  hsematoidin 
crystals,  was  coughed  up,  and  the  size  of  the  liver  diminished. 
Diagnosis — ^liver  abscess,  and  rupture  into  the  lung.  At 
the  operation  the  liver  was  studded  with  numerous  large 
and  small  whitish  hard  nodules,  and  the  operation  was 
abandoned.  Syphilis  was  denied,  but  iodide  was  adminis- 
tered internally,  and  in  the  course  of  a  year  his  general 
condition  became  excellent,  and  the  liver  diminished  in  size. 

Prognosis. — Risks  and  results  of  operation. — Hsemorrhage 
is  a  serious  risk  in  any  operation  for  the  removal  of  a  liver 
growth.     As  a  rule  an  exploratory  operation  is  necessary 


DISEASES    OF    THE    LIVER.  333 

before  it  can  be  settled  whether  the  growth  is  removable 
or  not.  Benign  tumours,  fibromata,  angiomata,  adenomata, 
and  cysts  have  been  successfully  removed,  and  in  rare 
instances  it  appears  that  primary  carcinoma  has  been 
successfully  dealt  with. 

//  no  operation  is  undertaken. — Malignant  growths  of 
course  cause  death  ;  benign  growths  often  attain  enormous 
proportions,  but  are  only  rarely  dangerous  to  life. 

LITERATURE. 

Langenbuch.  Chirurgie  der  Leber.  Deut.  Chir.  Stuttgart, 
1898. 

Kehr.  Lebergeschwiilste.  Prakt.  Chirurgie  v.  Bergmann, 
^likulicz,  u.  Bruns.     2nd  Ed.      1903. 

QuI^'CKK,  HopPE  -  Seyler.  Leberkrankheiten.  Nothnagel's 
Handbuch  d.  spez.  Pathol,  u.  Therap.,  1898. 

Ahlenstiel.  Lebergeschwiilste  und  ihre  Behandlung.  Arch.  f. 
klin.  Chir.,  Bd.  lii. 

Leppmann.  Ueber  der  echten  Cysten  der  Leber.  Deut.  Zeit.  f. 
Chir.,  Bd.  liv. 

Terrier  et  Auvrav.  Les  Tumeurs  du  Foie.  Rev.  de  Chir., 
1896. 

Langer.     Hamangiom  der  Leber.      Arch.  f.  klin.  Chir.,  Bd.  Ixiv. 

Keen.     Liver  Resection.     Annals  of  Surgery,  Sept.,  1899. 


HYDATID   CYST    OF    THE    LIYER. 

Etiology. — Hydatid  cyst  is  caused  by  the  entrance  by 
Avay  of  the  digestive  tract  of  the  eggs  of  TcBnia  echinococcus. 
The  embryo  penetrates  the  walls  of  the  intestine,  and 
is  carried  to  the  liver  by  the  portal  vein.  Hydatid  cyst  is 
exceptionally  common  in  some  regions,  particularly  in 
Australia,  Iceland,  Pomerania,  and  Mecklenburg.  Women 
are  more  commonly  affected  than  men.  The  multilocular 
cyst  is  probably  not  caused  by  the  same  parasite  as  the 
common  single  cyst,  and  has  a  different  geographical 
distribution  ;  it  is  comparatively  rare. 

Pathological  Anatomy. — There  is  usually  a  single  cyst 
situated  in  the  right  lobe  of  the  liver  ;  it  is  filled  with  a 
watery  fluid,  and  often  contains  numerous  daughter  cysts. 
The  fluid  is  limpid  or  slightly  opalescent,  its  sp.  gr.  is  1007 
to  1009,  and  it  contains  no  albumin.  When  the  cyst  is 
situated  in  tlie  centre  of  the  lobe  there  is  a  diffuse  enlarge- 
ment of  the  organ,  but  when  near  the  surface  it  is  found  as 


334  INDICATIONS    FOR    OPERATION    IN 

a  circumscribed  swelling.  Neighbouring  organs  may  be 
much  compressed,  particularly  the  lung,  as  the  cyst  is  often 
on  the  upper  convexity  of  the  liver.  Rupture  into  lung, 
bowel,  or  peritoneum  is  not  unusual;  secondary  suppuration 
is  common  ;  the  bile  channels  are  rarely  compressed.  When 
there  are  multiple  cysts*  the  liver  is  often  enormously 
enlarged  and  may  be  of  a  stony  hardness.  On  section  the 
organ  is  studded  wdth  numerous  small  cavities,  like  a 
Gruyere  cheese.  The  biliary  channels  are  more  frequently 
involved  in  this  form,  and  jaundice  and  hydrops  of  the  gall- 
bladder may  develop.  Secondary  cysts  may  be  found  in 
the  lungs  and  the  peritoneum  ;  suppuration  and  calcification 
are  not  uncommon. 

Clinical  Course. — Often  a  cyst  produces  no  symptoms. 
When  of  considerable  size,  the  liver  is  enlarged,  but  not 
tender  to  pressure,  and  there  is  no  jaundice  or  enlargement 
of  the  spleen.  If  the  cyst  can  be  directly  palpated  a  charac- 
teristic thrill  can  often  be  felt,  fluctuation  cannot  usually 
be  made  out,  and  often  the  swelling  is  intensely  hard.  When 
a  cyst  is  very  large  it  produces  symptoms  by  compression 
of  adjacent  organs  ;  for  example,  it  may  cause  dyspnoea, 
cough,  and  palpitation  by  pressure  on  the  diaphragm,  and 
through  it  on  the  lung  and  the  cardiac  area  ;  and  when 
encroaching  on  the  stomach  it  will  cause  nausea,  loss  of 
appetite,  and  a  sense  of  fullness  in  the  epigastrium.  If 
suppuration  supervenes  there  is  high  fever  of  an  intermittent 
or  remittent  type,  with  rigors  and  rapid  loss  of  strength  ; 
occasionally,  however,  there  is  no  pyrexia.  Perihepatic 
friction  is  usually  heard  when  suppuration  occurs,  and  the 
pus  may  rupture  into  a  neighbouring  organ  or  space  : 
pyaemia  is  relatively  frequent  as  a  result  of  this  complication. 
When  a  cyst  ruptures  into  the  lung,  scolices  are  usually 
coughed  up ;  when  rupture  takes  place  into  the  bile-ducts 
or  intestine,  the  scolices  may  be  found  in  the  faeces.  Rupture 
externally  is  rare.  If  some  injury  ruptures  a  cyst  into  the 
peritoneal  cavity,  severe  peritonitis  is  set  up. 

In  Echinococcus  multilocularis  jaundice  is  often  the 
first  and  persistent  symptom.  Melanotic  jaundice  is 
frequent.     The  liver  is  large,  hard,  nodular,  and  sometimes 


*  This  form  is  exceedingly  rare,  except  in  certain  districts  of  Germany 
and  Switzerland. 


DISEASES    OF    THE    LIVER  335 

presents  many  fluctuating  spots  ;  enlargement  of  the  spleen 
and  ascites  are  common.  When  the  condition  is  long  stand- 
ing, haemorrhages  often  occur ;  the  faeces  are  often  clay- 
coloured. 

Diagnosis. — The  history  is  often  of  assistance  in  regard 
to  the  patient's  place  of  residence  or  his  association  with 
dogs.  Apart  from  this  the  diagnosis  will  be  founded  on 
the  chronic  nature  of  the  condition,  the  absence  of  fever 
and  pain,  the  presence  of  an  elastic  tumour  with  the  charac- 
teristic hydatid  thrill.  When  the  cyst  is  subphrenic  the 
upper  outline  of  liver  dullness  is  markedly  dome-shaped 
towards  the  axilla,  the  lower  thoracic  outlet  is  much 
widened,  and  a  radiograph  will  often  demonstrate  the  cyst 
clearly.  Exploratory  puncture  has  frequently  settled  the 
diagnosis,  but  it  is  a  dangerous  proceeding  and  not  to  be 
recommended. 

The  diagnosis  of  Echinococcus  multilocularis  will  be 
assisted  by  enquiries  as  to  the  patient's  residence  ;  the 
disease  is  very  chronic  in  type,  and  the  general  condition 
is  relatively  good  ;  the  liver  is  nodular  and  exceedingly 
hard  in  parts ;  there  is  jaundice  and  enlargement  of  the  spleen, 
and  sometimes  fluctuating  areas  may  be  discovered. 

Acute  liver  abscess  is  sometimes  distinguished  with  diffi- 
culty from  a  suppurating  hydatid,  but  the  history  of  the 
preceding  illness  will  generally  clear  up  the  diagnosis.  Chronic 
liver  abscess  in  its  fever-free  stage  has  no  such  close  resem- 
blance to  a  suppurating  hydatid.  Malignant  tumours  of  the 
liver  develop  more  rapidly  and  produce  cachexia  earlier  ; 
they  are  usually  tender  to  pressure.  A  distended  gall-bladder 
has  a  characteristic  site  and  outline,  and  is  usually  associated 
with  attacks  of  gall-stone  colic,  either  recent  or  at  some 
earlier  period.  A  hydronephrotic  kidney  is  prominent  in 
the  lumbar  region,  the  colon  overlies  it,  and  it  often  shows 
marked  variations  in  size  ;  it  does  not  bulge  forward  the 
lower  costal  arches.  Pancreatic  cysts  lie  behind  the 
stomach  when  distended.  Ovarian  cysts  are  attached  to 
the  genital  organs  in  the  pelvis. 

A  syphilitic  liver  usually  shows  deep  furrowing  of  the 
anterior  border,  and  is  seldom  associated  with  such  intense 
jaundice  as  in  multilocular  hydatid.  Large  gummata  may 
simulate  cysts,  but  the  diagnosis  will  be  cleared  up  by 
antisyphilitic     treatment.     It     is     sometimes     difficult     to 


336  INDICATIONS    FOR    OPERATION    IN 

distinguish  hypertrophic  cirrhosis  from  muhilocular  hydatid, 
but,  as  a  rule,  there  are  not  the  bosses  of  various  sizes  on  the 
Uver  surface  which  are  characteristic  of  the  latter  ;  the 
residence  of  the  patient  is  an  important  aid  in  diagnosis. 

Sometimes  the  diagnosis  is  extremely  difficult,  as  in 
the  following  case.  A  woman,  aged  forty- five,  was  admitted 
into  hospital  under  my  care  with  a  rapidly-growing  abdominal 
swelling  ;  in  the  abdomen  there  was  a  freely  movable  cystic 
tumour  the  size  of  a  man's  head  ;  it  did  not  move  with 
respiration.  The  general  condition  was  good,  and  there 
was  no  fever.  On  distending  the  colon  the  growth  moved 
upwards  and  to  the  right  up  against  the  liver ;  no  connection 
could  be  made  out  with  ovaries  or  kidney.  The  patient 
had  been  operated  on  twenty-three  years  before  for  a  "  liver 
cyst,"  and  it  seemed  probable  that  a  portion  of  the  cyst 
had  been  left  behind,  and  it  had  re-formed.  At  the  operation 
a  large  hydatid  cyst  was  found  at  the  point  of  junction  of 
the  right  and  left  lobes  of  the  liver,  containing  vesicles  in 
part  suppurating.  The  patient  had  noticed  a  swelling 
about  the  size  of  a  small  apple  immediately  after  the  first 
operation  ;  this  had  remained  stationary  for  twenty-two 
years,  but  had  lately  begun  to  enlarge. 

INDICATIONS   FOR   OPERATION. 

Whenever  it  seems  reasonably  certain  that  a  palpable 
tumour  of  the  liver  is  hydatid  in  nature,  operation  should  be 
advised.  Both  forms  of  hydatid  are  to  be  treated  surgically. 
Operation  may  consist  of  puncture  through  the  abdominal 
wall  with  or  without  injection,  opening  the  cyst  with  the 
knife,  or  enucleation  of  the  cyst.  The  first-mentioned 
procedure  has  been  for  the  most  part  abandoned  ;  the  two 
latter  may  be  performed  in  one  stage  or  in  two  stages. 
Cysts  which  are  subphrenic  in  position  are  often  opened 
through  the  pleura.  Operation  is  urgent  when  a  cyst 
ruptures  into  the  peritoneal  cavity  ;  when  a  previously 
recognized  tumour  disappears  or  diminishes  in  size,  it  may  be 
consequent  on  some  abdominal  trauma,  and  when  this  is 
associated  with  severe  peritoneal  symptoms — rigidity, 
meteorism,  fever,  abdominal  pain,  signs  of  free  fluid  in  the 
peritoneal  cavity — and  collapse,  the  diagnosis  of  rupture 
is  clear.  The  appearance  of  an  urticarial  eruption  will 
confirm  the  diagnosis.     The  patient  will  often  say  that  he 


DISEASES    OF    THE    LIVER.  337 

felt  something  burst  in  the  abdomen.  Operation  is  also 
urgent  when  suppuration  occurs  in  a  cyst  ;  this  will  be 
shown  by  the  appearance  of  high  fever,  rigors,  rapid 
increase  in  size  of  the  tumour,  and  increased  tenderness  to 
pressure. 

Contra-indications. — Exploratory  puncture  of  a  hydatid 
cyst  is  not  a  justifiable  proceeding  ;  subsequent  leaking 
may  give  rise  to  fatal  peritonitis,  or  to  diffusion  of  the 
hydatids  throughout  the  peritoneum.  There  are  the  same 
objections  to  puncture  with  a  trocar  through  the  abdominal 
parietes. 

Risks  of  operation. — Puncture  followed  by  drainage  is 
particularly  dangerous  ;  it  is  attended  by  a  mortality  of 
28  per  cent.  Peritonitis  has  often  followed  immediately 
after  this  procedure.  Profuse  haemorrhage  may  follow 
enucleation.  Operation  in  two  stages  and  drainage  of  the 
cyst  is  a  safe  proceeding  ;  all  the  forty-eight  cases  reported 
by  Langenbuch  recovered. 

Prognosis. — Results  of  operation. — Almost  all  cases  of 
unilocular  cyst  may  be  successfully  treated  by  operation. 
Occasionally  there  are  troubles  from  ventral  hernia  or 
adhesions. 

//  no  operation  he  done,  hydatid  cysts  tend  to  suppurate  ; 
whether  suppurating  or  not,  they  may  rupture  into  neigh- 
bouring organs.  Rupture  into  the  peritoneal  cavity  is 
fatal  in  90  per  cent ;  rupture  into  the  pleura,  fatal  in  80  per 
cent  ;  rupture  into  the  bile  channels,  in  70  per  cent  of  cases. 
A  suppurating  hydatid  may  cause  general  septicaemia. 

Both  types  of  hydatid  are  compatible  with  life  for  long 
periods.  In  the  case  which  I  have  described  above  the  cyst 
had  been  present  for  twenty-three  years. 

LITERATURE. 

Hoppe-Seyler  (Quincke).  Krankheiten  der  Leber.  Nothnagel's 
Handbuch  d.  spez.  Pathol,  u.  Therap.     Bd.  xviii.      1899. 

Langenbuch.     Chirurgie.  der  Leber.     Deut.  Chir.  Stuttgart. 

Kehr.  Krankheiten  der  Leber.  Handbuch  d.  prakt.  Chir.  v. 
Bergmann,  MikuUcz,  u.  Bruns.     2nd  Ed.      1903. 

KoRTE.  Erfahrungen  iiber  die  Operation  von  Leber-Echinococcen. 
Beitr.  z.  klin.  Chir.     Bd.  xxiii. 

Bruns.  Leberresektion  bei  multilocularem  Echinococcus.  Beitr. 
z.  khn.  Chir.,  Bd.  xvii. 

Posadas.     Traitement  des  Kystes  Hydat.     Rev.  de  Chir.,  1899. 

-Madelung.     Chirurgischc     Bchandlung     der     Leberkrankheitcn. 

22 


338  INDICATIONS    FOR    OPERATION    IN 

Spez.  Therap.  von  Penzoldt-Stintzing.  3rd  Ed.  ;  also  :  Post- 
operative Pfropfung  von  Echinococcencysten.  Mitteil.  a.  d.  Grenzge- 
biete  d.  Med  u.  Chir.     Bd.  xiii. 

PossELT.  Der  Echinococcus  Multilocularis.  Deut.  Arch  f.  klin. 
Med.     Bd.  xli. 

RouTiER.  Bull,  et  Mem.  de  la  Societe  de  Chir.  de  Paris,  1899, 
p.  715. 

QuENU,  PoTHERAT,  TuFFiER.  Ibidem,  1900,  p.  314;  and  1903, 
p.  719. 

Deve.     De  rEchinococcose  Secondaire.     These  de  Paris,     1901. 


ABSCESS    OF    THE    LIVER. 

Etiology. — Dysenter}'  is  the  most  common  primary 
cause  of  liver  abscess.  The  condition  may  also  follow 
inflammatory  affections  in  any  part  of  the  portal  system, 
for  example,  appendicitis  ;  it  may  result  from  direct  injury 
to  the  liver,  wound  infection,  and  pyaemia.  Gastric  ulcera- 
tion, inflammatory  affections  of  the  gall-bladder  and  ducts, 
particularly  that  consequent  on  cholelithiasis,  may  also 
cause  liver  infection.  A  hydatid  cyst  may  become  a  liver 
abscess  by  suppuration.  The  tropical  abscess  is  the  most 
common  type  ;  it  occurs  much  more  frequently  in  men 
than  in  women,  and  is  preceded  by  dysentery. 

Pathological  Anatomy. — Liver  abscesses  are  single 
and  multiple  ;  75  per  cent  of  tropical  liver  abscesses  are 
single.  Multiple  abscesses  result  from  infection  conveyed 
to  the  liver  by  the  portal  venous  system  or  the  hepatic 
artery  or  the  bile -ducts.  An  abscess  may  be  acute  and 
surrounded  by  an  area  of  necrotic  liver  tissue,  or  more 
chronic  in  type,  in  which  case  it  is  often  more  or  less  encap- 
suled  ;  old  abscesses  are  sometimes  in  part  calcareous.  Not 
uncommonly  rupture  occurs  into  some  neighbouring 
structure  ;  this  takes  place  most  frequently  into  the  lung 
(about  10  per  cent  of  cases),  following  an  adherent  peri- 
hepatitis ;  rupture  through  the  abdominal  wall  or  into  the 
peritoneum  is  comparatively  uncommon.  Some  abscesses 
contain  as  much  as  several  litres  of  pus.  The  solitary 
abscess  occurs  five  times  more  frequently  in  the  right  than 
the  left  lobe  ;  peritoneal  adhesions  to  the  site  of  the  abscess 
are  very  often  absent  ;   the  contents  are  often  sterile. 

Clinical  Course. — Pygemic  abscesses  of  the  liver  do  not 
as  a  rule  give  rise  to  any  very  prominent  signs ;  those  which 


DISEASES    OF    THE    LIVER.  339 

follow  intestinal  affections  present,  on  the  other  hand,  a 
characteristic  group  of  symptoms.  There  are  the  general 
symptoms  :  prostration,  nausea  and  vomiting,  remittent  or 
typically  intermittent  fever,  and  rigors ;  and  the  local 
symptoms.  The  liver  is  enlarged,  either  as  a  whole  or  in 
one  particular  direction  ;  if  the  abscess  is  near  the  convexity 
the  enlargement  upwards  is  dome-shaped  in  the  direction 
of  the  axilla.  There  is  usually  pain,  referred  to  the  region 
of  the  liver,  and  the  organ  is  also  often  tender  to  pressure  ; 
there  are  intestinal  disturbances,  vomiting  and  diarrhoea, 
and  radiating  pains  in  the  direction  of  the  shoulder,  but  these 
are  seldom  severe.  Occasionally  it  is  possible  to  make  out 
a  definitely  local  enlargement,  with  fluctuation.  As  the 
disease  progresses,  rigors,  followed  by  profuse  perspiration, 
become  more  frequent.  If  perforation  occurs  into  the  lung, 
the  patient  coughs  up  first  a  red  blood-stained  sputum, 
and  then  quantities  of  purulent  matter  containing  hsema- 
toidin  crystals  or  bile.  There  is  usually  no  jaundice  ;  this 
is  most  commonly  associated  with  abscesses  originating 
in  a  septic  cholangitis. 

In  chronic  liver  abscess,  progressive  weakness  and  loss  of 
flesh  are  the  chief  symptoms  which  attract  attention. 

Diagnosis. — Very  important  is  a  careful  enquiry  into 
the  history  as  to  the  existence  of  some  one  of  the  already- 
mentioned  antecedents  of  liver  abscess.  The  diagnosis 
will  be  based  on  the  presence  of  the  symptoms  just 
enumerated.  According  to  Koch,  the  attitude  is  charac- 
teristic :  the  patient  bends  to  the  right  to  relax  the  pressure 
on  that  side.  Leucocytosis  and  peptonuria  will  point  to 
the  presence  of  pus.  A  skiagram  will  sometimes  show 
an  abnormal  outline  of  the  upper  border  of  the  liver  shadow  ; 
exploratory  puncture  will  decide  the  question.  An  impor- 
tant rule  is  that  a  diagnosis  of  liver  abscess  is  only  justifiable 
when  it  is  possible  with  certainty  or  great  probability  to 
diagnose  the  original  source  of  suppuration  (Leube). 

Regarding  the  diagnosis  of  the  site  of  the  abscess,  the 
following  points  are  important : — If  the  diaphragm  is  pushed 
up  to  the  third  or  fourth  rib,  and  the  liver  enlargement  is 
sharply  defined  on  percussion,  the  abscess  must  lie  imme- 
diately under  the  diaphragm.  If  the  inferior  border  of  the 
liver  is  exceptionally  low,  the  abscess  is  not  necessarily  here ; 
only  if  the  enlargement  here  is  localized  and  circumscribe 


340  INDICATIONS    FOR    OPERATION    IN 

is  one  justified  in  so  deciding.  When  palpation  of  the  liver 
reveals  a  constantly  tender  spot  the  abscess  is  probably 
close  beneath  the  surface  here.  If  the  liver  dullness  alters 
with  changes  of  position  there  are  probably  no  peritoneal 
adhesions  ;  fixity  of  the  liver  does  not,  however,  absolutely 
indicate  their  presence ;  this  can  be  diagnosed  only  from  the 
existence  of  true  local  inflammatory  oedema  of  the  thoracic 
or  abdominal  wall. 

Differential  diagnosis  from  carcinoma  may  be  particularly 
difficult,  because  a  nodule  of  growth  may  soften  and  be 
associated  with  typical  intermittent  fever  ;  the  discovery 
of  metastases  would  decide  the  question.  Gastric  cancer 
may  be  confused  with  an  abscess  of  the  left  lobe,  but  will 
be  distinguished  by  signs  of  obstruction  to  the  passage 
of  stomach  contents  and  alteration  in  the  stomach  secretion 
(absence  of  hydrochloric  acid).  Exploratory  puncture 
and  radiographic  examination  will  exclude  pleurisy  or 
pneumonia.  Differentiation  from  pleurisy  will  be  further 
facilitated  if  one  remembers  that  in  liver  abscess  the  dullness 
will  probably  show  a  characteristic  and  circumscribed 
outline,  and  the  line  will  descend  as  it  approaches  the 
vertebral  column.  Hydatid  cyst  develops  more  slowly 
than  abscess,  and  runs  an  apyrexic  course.  Empyema  of 
the  gall-bladder  is  distinguished  by  its  characteristic  shape 
and  position.  In  perinephritic  abscess  there  is  usually 
a  history  of  antecedent  renal  disease,  tenderness  on  pressure 
over  the  kidney,  and  oedema  in  the  loin.  Hydro-  and 
pyonephrosis  are  characterized  usually  by  variations  in  the 
size  of  the  swelling,  associated  with  intermittent  polyuria. 
In  malaria  there  is  splenic  enlargement,  which  is  not  present 
in  liver  abscess. 

INDICATIONS   FOR   OPERATION. 

If  clinical  signs  point  to  abscess  of  the  liver,  operation, 
that  is  to  say  puncture  or  incision,  should  be  done  without 
delay.  Exploratory  puncture  should  be  done  only  when 
the  surgeon  is  prepared  at  once  to  open  the  abdomen  if 
necessary.  When  the  liver  abscess  is  complicated  by 
empyema,  suitable  surgical  treatment  must  be  undertaken 
for  this  condition  also  ;  that  is  to  say,  rib  resection  and 
drainage. 

Signs   of  perforation   into   thorax   or   abdomen   demand 


DISEASES    OF    THE    LIVER.  341 

immediate  operation.  Perforation  into  the  peritoneal 
cavity  is  shown  by  sudden  agonizing  abdominal  pain, 
collapse,  and  muscular  rigidity,  associated  with  rapid 
alteration  in  the  configuration  of  the  liver  demonstrated  by 
palpation,  percussion,  or  radiography. 

Contra-indications. — When  the  signs  of  abscess  are  distinct, 
the  only  contra-indications  are  such  collapse  as  will  neces- 
sarily render  any  operation  fatal,  and  the  presence  of 
universal  pyaemia  with  multiple  septic  foci.  When  the 
diagnosis  is  doubtful,  the  advisability  of  exploratory  opera- 
tion will  be  judged  from  the  condition  of  the  patient. 
Exploratory  puncture  must  never  be  done  below  the  costal 
border,  and  is  never  justified  unless  operation  can  follow 
at  once. 

Prognosis. — Of  operation. — The  earlier  the  operation  the 
better  the  prognosis  ;  this  is  shown  in  statistics.  Some 
surgeons  report  only  one  fatality  in  seven,  others  record  a 
mortality  of  70  per  cent  and  over.  Perutz  has  collected 
182  cases  from  the  literature  of  the  last  ten  years,  with  an 
operative  mortality  of  24  per  cent.  Out  of  48  cases  operated 
on  abdominally  35  recovered  ;  in  132  transpleural  operations 
1 01  recovered.  Of  25  cases,  in  which  at  the  time  of  the 
operation  there  was  some  complication  (subphrenic  abscess, 
empyema,  rupture  into  the  lungs),  8  recovered  and  17  died. 
In  most  cases  the  recovery  was  complete.  Koch  reported 
42  cases,  38  of  which  were  cured  by  operation.  The  healing 
process  is  slow  and  runs  to  six  weeks  or  more.  The  statistics 
of  Jimenez  show  that  puncture  is  a  dangerous  proceeding 
owing  to  the  risk  of  infection  of  the  peritoneum ;  of  297  cases 
punctured  82  per  cent  died.  Puncture  may  cause  death 
from  haemorrhage,  or  allow  the  abscess  to  empty  itself 
slowly  into  the  peritoneum  and  set  up  peritonitis. 

//  no  operation  is  done,  the  abscess  may  become  encapsuled 
and  give  rise  to  few  symptoms  for  a  long  time  ;  it  often, 
however,  progresses  again  in  consequence  of  some  trauma. 
In  most  cases  the  abscess  steadily  enlarges,  and  usually 
ruptures  into  a  neighbouring  organ  ;  rupture  into  the  air 
passages  and  bowel  often  ends  in  recovery.  The  mortality 
from  liver  abscess  not  operated  on  is  the  same  for  tropical 
and  non-tropical  cases,  according  to  Langenbuch,  that  is  to 
say,  one  recovery  to  four  deaths.  The  average  duration  of 
life  in  cases  not  operated  on  is  from  i  to  5  months. 


34^  INDICATIONS    FOR    OPERATION    IN 

LITERATURE. 

LANGEN3UCH.  Chirurgie  der  Leber.  Deut.  Chir.  Stuttgart, 
1899. 

Quincke  und  Hoppe-Seyler.  Leberkrankheiten.  Nothnagel's 
Handbuch  f.  d.  spez.  Pathol,  u.  Therap.     Wien. 

Kehr.  Leberkrankheiten.  Handbuch  d.  prakt.  Chir.  Bergmann, 
MikuHcz,  u.  Bruns.     2nd  Ed.      1903. 

Perutz.  Der  Leberabscess.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.'Chir.,  1903. 

Zancarol.  Sur  la  Pathogenic  des  Absces  du  Foie.  Rev.  de 
Chir.,  1893  ;  and  Traitement  Chirurgical  des  Absces  du  Foie. 
Paris,  1893. 

^IcLeod.     Tropical  Liver  Abscess.     Brit.  ^led.  Jour.,  1900. 

British  Medical  Associaticn.     Discussion  on  Dysentery  and 
Tropical  Liver  Abscess.     Lancet,  August  16,  1902. 
i    Bertrand  et  FoNTAN.      Traite  de  Hepatite  Suppuree  des  Pays 
Chauds.     Paris,  1875. 

Gasser.  Absces  du  Foie.  ^lanuel  de  iNIedic.  de  Debove  et 
Achard.     Tome  vi. 

Koch,  J.  A.  Ueber  tropische  Leberabscesse.  Mitteil.  a.  d. 
Grenzgebiete  d.  Med.  u.  Chir.      1904.     xiii. 

Scheube,  B.  Die  Krankheiten  der  warmen  Lander.  3rd  Ed. 
Jena,  1903. 

RoBiNSCN.  Tropical  Abscess  of  the  Liver.  Jour.  Amer.  Med. 
Assoc,  1901,  No.   19. 

Smith.  The  Diagnosis  and  Surgical  Treatment  of  Tropical  Liver 
Abscess.     Brit.  ^led.  Jour.,  Sept.   i,   1900. 

Boinet.  Diagnostic  des  Formes  Latentes  de  I'Absces  du  Foie. 
Gaz.  des  Hopit.     March  5,  1901. 

Lesage.  Absces  du  Foie  d'Origine  Dysenterique.  Soc.  de 
Biologic,  No.  21,  1902. 

i    Malbot.     Les  Absces  du  Foie  en  Algerie.     Arch.  Gener.  de  Med. 
Oct.,  1899. 


ATROPHIC    CIRRHOSIS   OF    THE    LIVER. 

Etiology. — Alcoholism  is  by  far  the  most  common 
cause  of  atrophic  cirrhosis  ;  it  is  occasionally  due  to  syphilis, 
malaria,  and  chronic  intoxications. 

Pathological  Anatomy. — In  this  affection  the  liver 
shows  primarily  a  diffuse  hyperplasia,  and,  secondarily, 
shrinking  and  contraction  of  the  interlobular  connective 
tissue.  A  considerable  amount  of  the  hver  parenchyma 
atrophies,  and  many  of  the  branches  of  the  portal  venous 
system  are  obhterated.  In  the  later  stages  the  liver  as 
a  whole  is  shrunken  and  the  surface  corrugated,  the  portal 


DISEASES    OF    THE    LIVER.  343 

vein  and  its  brandies  are  distended,  and  the  spleen  is  usually 
enlarged.  Collateral  venous  channels  are  often  enlarged 
and  varicose,  and  particularly  those  at  the  lower  extremity 
of  the  oesophagus. 

Clinical  Course. — The  stage  of  enlargement  is  often 
undetected  clinically ;  it  is  followed  by  the  stage  of  shrinking, 
in  the  course  of  which  the  liver  becomes  firmer  to  the  touch. 
The  surface  is  uneven  and  the  edge  firm  and  easily  palpable. 
When  the  condition  has  made  considerable  progress  the 
spleen  is  found  to  be  enlarged.  Ascites  often  appears  at  a 
relatively  early  stage,  but  is  occasionally  late.  It  develops 
sometimes  insidiously,  sometimes  suddenly  ;  it  is  painless 
throughout,  and  is  often  extreme. 

Haemorrhages  from  the  gastro-intestinal  tract  frequently 
occur,  and  often  constitute  one  of  the  early  symptoms. 
Varicose  distension  of  the  veins  of  the  abdominal  wall  is  often 
to  be  seen,  and  sometimes  has  the  formation  of  the  so-called 
"  caput  medusae "  around  the  umbilicus.  Occasionally 
the  exudation  is  hsemorrhagic,  and  when  a  pleural  effusion 
is  also  present  it  may  have  the  same  characters.  Tubercu- 
losis of  the  lungs  frequently  complicates  the  condition  ;  it 
is  rare  to  find  jaundice,  but  it  is  occasionally  present  in 
advanced  cases. 

Diagnosis. — The  diagnosis  will  be  based  on  the  charac- 
teristic changes  in  the  consistence  and  size  of  the  liver, 
the  presence  of  ascites  and  enlargement  of  the  spleen,  and 
the  occurrence  of  haemorrhages  into  the  gastro-intestinal 
tract.  When  a  mitral  or  tricuspid  affection  is  present  and 
the  hepatic  symptoms  improve  after  the  administration  of 
cardiac  remedies,  the  case  is  one  of  venous  congestion  of 
the  liver.  Chronic  hyperplastic  perihepatitis  is  often 
difficult  to  distinguish  from  cirrhosis  ;  in  its  early  stages 
there  is  often  perihepatic  friction,  and  this  condition  must 
always  be  thought  of  in  cases  where  there  is  no  alcoholic 
history,  when  there  is  an  accompanying  non-tubercular 
pleuritic  and  pericardial  affection,  and  the  ascites  remains 
stationary  for  some  years. 

Obstruction  at  the  hilum  of  the  liver,  for  example  by 
new  growth,  causes  intense  jaundice  as  well  as  ascites. 
Tubercular  peritonitis  does  not  run  an  apyrexic  course 
throughout,  and  shows  a  marked  tendency  to  the  formation 
of  localized  collections. 


344  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS   FOR   OPERATION. 

Surgical  treatment  may  consist  simply  of  puncture  for 
the  temporary  relief  of  ascites,  or  an  attempt  may  be  made 
to  give  permanent  relief  by  the  opening  up  of  new  venous 
channels  to  supplement  the  obstructed  portal  circulation. 

Tapping  is  indicated  (a)  when  the  pressure  of  the  fluid 
threatens  death  from  suffocation  ;  {b)  in  the  earlier  stages 
when  the  respiration,  circulation,  and  nutrition  are  embar- 
rassed. Many  writers  advocate  drawing  off  ascitic  fluid 
at  a  still  earlier  period,  but  my  own  opinion  coincides  with 
that  of  the  majority,  who  are  in  favour  of  postponing  the 
tapping  until  one  or  other  of  the  above-named  symptoms 
has  made  its  appearance.  Tapping  frequently  repeated 
entails  a  not  inconsiderable  risk  owing  to  the  loss  of  albumin, 
and  should  therefore  be  avoided  when  possible  ;  it  is  not 
necessary  to  repeat  it  until  the  patient  again  shows  signs 
that  his  circulatory,  respiratory,  or  digestive  systems  are 
suffering  from  the  ascites. 

The  Talma-Morison  operation,  which  consists  of  fixation 
of  the  omentum,  liver,  and  spleen  to  the  abdominal  parietes 
for  the  purpose  of  opening  up  new  venous  channels,  is  indi- 
cated when  medical  treatment  fails  to  influence  the  reaccumu- 
lation  of  fluid  and  tapping  has  to  be  repeated,  whether  the 
liver  is  small  and  shrunken  or  not.  The  diagnosis  must  be 
definite  before  the  operation  is  advised  ;  if  postponed  to 
the  late  stages,  changes  in  the  peritoneum  may  render  it 
ineffective.  I  view  also  as  an  indication  for  this  operation 
the  occurrence  of  repeated  profuse  haemorrhage  into  the 
stomach  and  intestine,  even  in  cases  where  ascites  is  absent 
or  slight,  and  there  is  no  jaundice  ;  these  hjemorrhages 
point  to  pronounced  engorgement  of  the  portal  circulation, 
and  not  infrequently  cause  death  ;  I  have  seen  several  fatal 
cases. 

Contra-indications. — Talma  cites  as  contra-indications  to 
his  operation  the  presence  of  long-standing  jaundice, 
urobilinuria,  acholia  or  hypocholia  of  the  faeces,  and 
xanthoma.  Serious  cardiac  or  vascular  lesions  also  contra- 
indicate  it.  Operation  is  also  inadvisable  in  cases  where 
the  cirrhosis  is  of  long  standing  and  the  general  symptoms 
are  of  a  serious  type,  as  under  these  circumstances  the 
function  of  the  liver  cells  is  largely  destroyed  and  there  is 


DISEASES    OF    THE    LIVER.  345 

considerable  risk  of  auto-intoxication.  Another  contra- 
indication is  the  occurrence  of  repeated  haemorrhages  from 
the  mucous  membranes,  associated  with  jaundice. 

Risks  of  operation. — Out  of  164  cases  of  omentofixation 
collected  by  Zesas,  72  ended  fatally.  Purulent  peritonitis 
figured  relatively  frequently  as  a  cause  of  death  among 
these.  There  is  a  possibility  of  auto-intoxication,  owing  to 
the  exclusion  of  the  liver  function  in  removing  toxic 
material  from  the  blood.  The  intestine  may  be  kinked  if 
the  omentum  is  made  taut  by  suture  (Franke).  Usually 
the  dangers  of  anaesthesia  have  been  avoided  by  performing 
the  operation  under  a  local  anaesthetic.  The  operation 
should  not  take  long,  but  the  patients  are  always  in  an 
enfeebled  condition,  and  the  statistics  show  that  many 
of  the  deaths  have  occurred  from  shock.  Puncture  of 
the  abdomen  under  aseptic  precautions  is  practically  free 
from  risk  ;  in  one  of  my  cases  fatal  heemorrhage  from 
dilated  oesophageal  veins  followed  tapping,  but  whether 
the  tapping  had  anything  to  do  with  the  accident  is 
uncertain. 

Prognosis. — Results  of  operation. — Of  Zesas'  164  cases 
51  were  cured,  but  it  must  be  stated  that  the  after  history 
was  followed  in  only  a  small  proportion  of  the  cases  for 
periods  of  from  three  months  to  two  and  three-quarter 
years.  Twenty-six  of  the  remainder  were  improved, 
and  eleven  showed  no  improvement.  Of  seven  cases 
reported  by  Pal  and  Frank  three  were  cured,  in  two  the 
ascites  returned,  and  two  died,  but  not  in  consequence  of 
the  operation.  Of  great  interest  is  a  later  communication 
by  Pal,  that  in  one  patient  in  whose  case  the  operation  had 
been  classed  as  a  failure  clinical  signs  of  recovery  commenced 
a  year  and  a  half  later.  The  operation  opens  up  new 
channels  for  the  portal  blood,  and  these  remain  permanently 
open.* 

Without'  operation. — Most  cases  of  cirrhosis  of  the  liver 
end  fatally  after  a  variable  period  when,  after  the  first 
tapping,  the  fluid  reaccumulates  in  spite  of  a  rigidly- 
restricted  diet   and    diuretics.       Death   is   in   many   cases 


*  Of  255  cases  collected  by  Bunge,  66  were  cured,  27  improved  ;  in  35 
there  was  no  improvement,  and  in  the  remainder  death  was  recorded,  not 
necessarily  connected  with  the  operation  [Trans.]. 


346  INDICATIONS    FOR    OPERATION    IN 

due  to  repeated  haemorrhages  from  the  gastro-intestinal 
tract.  In  a  small  number  of  cases  spontaneous  arrest  has 
occurred  and  even  clmical  recovery,  when  the  habits 
causing  the  affection  were  surrendered. 

LITERATURE. 

Zesas.  Die  Talma'sche  Operation  bei  Lebercirrhose,  ihre  Erfolge 
u.  Resultate.      Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1904. 

Friedmaxx.  Die  operative  Behandlung  der  Lebercirrhose. 
Ibid,  No.  15,  1900. 

Quincke.  Leberkrankheiten.  Nothnagel's  Handbuch  d.  spez. 
Path.  u.  Therapie.     Wien. 

Talma.     Berl.  khn.  Wochens.,  Sept.  19,  1S98,  and  July  30,  1900. 

^NIuLLER.  Zur  Frage  der  operativen  Ascitesbehandlung.  Arch. 
f.  khn.  Chir.      1902. 

Leport.  Chirurgie  du  Grosse  Ascites.  La  Semaine  Medicale. 
May  25,  1903. 

Lenzmaxn.  Zur  Frage  der  Indikationen  und  der  Erfolge  der 
Talma' schen  Operation  bei  der  Atrophischen  Lebercirrhose.  Deut. 
med.  Wochens.     Xo.  48.      1903. 

J.  Pal.  Operative  Behandlung  der  Lebercirrhose.  Gesellsch.  d. 
Aerzte  in  Wien,  Feb.  28,  1902.  Wiener  khn.  Wochens.,  10  and 
II,  1902,  and  1 1,  1904. 

BuxGE.     Die  Talma-Drummonsche  Operation.     Jena.      1905. 


MOVABLE    LIYER. 

Etiology. — Hepatoptosis  may  be  due  to  congenital 
anomalies,  to  the  pressure  of  tight  corsets,  to  injury,  to 
rapid  loss  of  flesh,  or  to  multiple  pregnancies. 

Pathological  Anatomy. — The  liver  is  displaced  from 
the  right  hypochondrium  downwards,  and  is  no  longer 
in  contact  with  the  under  surface  of  the  diaphragm.  The 
organ  may  descend  horizontally  and  rotate  on  its  frontal 
axis,  or  the  right  lobe  may  be  chiefly  affected  and  reach  the 
iliac  crest.  It  is  often  fixed  by  adhesions  in  its  new  position, 
and  may  be  much  altered  in  shape.  There  is  often  an 
accompanying  ptosis  of  other  organs,  for  example,  the 
spleen  and  the  kidneys. 

Clinical  Course. — In  cases  where  the  dislocation  takes 
place  suddenly  there  are  acute  symptoms,  abdominal  pain, 
and  collapse.  The  subacute  and  chronic  cases  present  a 
great  variety  of  symptoms.  There  are  often  vague  pains, 
which  come  on  in  attacks,  particularly  when  the  patient 


DISEASES    OF    THE    LIVER.  347 

sneezes,  coughs,  or  raises  the  arms  ;  jaundice  is  sometimes 
present,  due  to  kinking  of  the  bile-ducts  ;  palpitation 
is  common.  The  displacement  of  the  liver  is  revealed  by 
palpation  and  percussion  ;  it  is  not  tender  to  pressure. 
When  the  patient  stands  the  epigastrium  usually  shows 
depression. 

Diagnosis. — The  physical  signs  render  the  diagnosis 
easy,  particularly  when  the  liver  can  be  replaced  upwards 
into  its  normal  position.  It  is  distinguished  from  a 
movable  kidney  by  the  presence  of  intestine  in  front  of  the 
latter  ;  a  renal  swelling  is  shown  to  be  distinct  from 
the  liver  by  percussion  and  palpation,  and  the  physical 
signs  also  differentiate  it  from  tumours  of  the  liver,  of  the 
intestine,  or  of  the  peritoneum. 

INDICATIONS   FOR   OPERATION. 

If  the  liver  is  considerably  displaced,  and  the  displacement 
gives  rise  to  persistent  and  marked  symptoms  which  cannot 
be  relieved  by  bandage  or  other  appliance,  if  also  the  patient 
is  unable  to  follow  his  occupation  and  is  depressed  by  his 
condition,  then  operation  is  justifiable.  The  operation 
consists  in  fixing  the  liver  in  its  proper  position  after 
freshening  its  upper  surface  in  order  to  obtain  adhesions 
over  as  wide  an  area  as  possible. 

Contra-indications. — If  the  symptoms  are  slight  and 
principally  hysterical,  operation  is  not  advisable  ;  under 
such  circumstances  it  is  quite  possible  that  operation 
will  neither  cure  nor  relieve.  There  is  little  prospect  of 
success  when  hepatoptosis  is  merely  part  of  a  general 
enteroptosis.    Operation  is  contra-indicated  in  advanced  age. 

Prognosis. — Results  and  risks  of  operation. — The  imme- 
diate risks  of  operation  under  strict  asepsis  are  slight,  but 
damage  may  be  done  to  the  bowel  or  some  other  organ  in  the 
course  of  separating  adhesions.  The  majority  of  patients 
operated  on  are  relieved  of  their  symptoms,  and  are 
enabled  to  resume  work. 

Without  operation. — There  are  no  serious  risks  attached 
to  this  condition,  but  so  long  as  it  is  unrelieved  the  patient 
will  probably  complain  of  persistent  and  severe  pain  and 
sensations  of  dragging,  and  will  be  permanently  unable  to 
work. 


348  INDICATIONS    FOR    OPERATION    IN 

LITERATURE. 

Teleky.  Die  Wanderleber.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Chir.      1901. 

Quincke.  Krankheiten  der  Leber.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Therap.     Wien.      1899. 

Langenbuch.  Chirurgie  der  Leber  u.  Gallenblase.  Deut. 
Chirurgie,  45c.     Stuttgart:    Enke. 

EiNHORN.  Die  Wanderleber  und  ihre  klinische  Bedeutung.  Zeits. 
f.  diat.  u.  physikal.  Therapie.     Bd.  iv.      1900. 

BoTTicHER.  Ueber  Hepatopexie.  Deut  Zeit.  f.  Chir.  Bd.  Ivi. 
1900. 

Pantaloni.    Chirurgie  du  Foie  et  desVoiesBiliaires.     Paris.    1899. 

Terrier  et  Auvray.  Le  Foie  Mobile,  etc.  Rev.  de  Chir.,  1897, 
p.  621,  and  1898,  Nos.  5  and  6. 

Treves.     Ptosis  of  the  Liver.     Lancet,  May   12,  1900. 


THE    CONSTRICTED    LIYER. 

Etiology. — The  long-continued  compression  of  the 
thorax  by  tight  corsets  produces  a  characteristic  series  of 
anatomical  changes  and  symptoms. 

Pathological  Anatomy. — There  are  various  types  of 
the  deformity  which  may  be  produced  by  tight  lacing. 
In  the  only  type  which  presents  any  surgical  interest,  a 
portion  of  the  right  lobe  is  more  or  less  separated  off  from 
the  rest  of  the  liver  in  advanced  cases  the  hepatic  tissue 
is  completely  destroyed  at  the  point  of  greatest  pressure, 
and  the  thickened  and  bulky  mass  of  separated  liver  is 
attached  to  the  rest  of  the  organ  only  by  connective  tissue, 
vessels,  and  bile-ducts. 

Clinical  Course. — In  most  cases  compression  by  the 
corset  gives  rise  to  no  symptoms.  Sometimes  the  separated 
lobe,  when  swollen  and  oedematous,  causes  a  sense  of 
weight  and  pressure  which  gives  rise  to  a  considerable 
amount  of  distress.  The  pain  may  radiate  to  the  thorax 
and  the  shoulder.  There  may  be  vomiting  and  tenderness 
on  pressure  over  the  mass.  Sometimes  the  artificially- 
formed  lobe  is  very  mobile  ;  movable  kidney  is  a  frequent 
complication.  The  line  of  intersection  has  a  horizontal 
direction,  and  the  vertical  measurement  of  the  liver  is 
increased,  especially  towards  the  right. 

Diagnosis. — In  cases  which  are  not  very  advanced  it 
is  easy  to  make  out  on  palpation  that  the  strangulated 


DISEASES    OF    THE    LIVER.  349 

mass  belongs  to  the  liver,  and  in  such  cases  it  moves  with 
respiration.  At  a  later  stage  it  becomes  more  movable 
and  more  displaced,  and  does  not  move  in  respiration.  As 
a  rule  it  is  easily  distinguished  from  a  movable  kidney, 
as  the  latter  occupies  chiefly  the  lumbar  region,  while  the 
liver  mass  is  easily  felt  on  palpation  of  the  abdomen  from 
the  front.  It  is  often  useful  to  place  the  patient  half  over 
on  the  left  side,  when  the  liver  lobe  sinks  to  the  left  and 
the  movable  kidney  is  more  easily  palpable.  The  ascending 
and  transverse  colon  lie  behind  the  mass.  Careful  examina- 
tion will  be  necessary  to  distinguish  this  condition  from 
new  growths  of  the  intestine  and  of  the  gall-bladder  and 
from  perityphlitis,  etc.  However  enlarged  and  swollen 
the  lobe  may  become,  it  remains  mobile;  jaundice  is  practi- 
cally never  present. 

INDICATIONS   FOR   OPERATION. 

Operation  is  only  justified  in  advanced  types  of  the 
condition,  where  the  anatomical  changes  are  extreme  and 
a  freely-movable  lobe  is  present  which  has  caused  pronounced 
symptoms  for  some  considerable  time,  making  the  patient 
unable  to  work  and  low-spirited.  Other  treatment  should 
always  be  tried  before  operation  is  advised.  Notwith- 
standing the  frequency  of  this  deformity  operation  is  rarely 
indicated,  if  one  may  judge  from  the  small  number  of  cases 
recorded.  The  symptoms  are  rarely  so  extreme  as  to  make 
it  necessary.  I  have  myself  seen  many  marked  cases,  but 
have  never  judged  it  necessary  to  advise  operation.  The 
procedure  employed  is  either  fixation  of  the  lobe  to  the 
abdominal  parietes  or  resection. 

Contra-indications. — When  the  separated  lobe  is  swollen 
and  painful,  and  this  state  of  affairs  has  been  present  only 
a  short  time,  expectant  treatment  should  always  be  tried 
first,  and  under  its  influence  the  pain  and  swelling  will 
usually  disappear.  When  there  is  reason  to  believe  that 
most  of  the  symptoms  are  hysterical  and  nervous  rather 
than  due  to  strangulation  of  the  lobe,  no  operation  should 
be  done. 

Prognosis. — Risks  of  operation. — Neither  ventrofixation 
nor  resection  is  free  from  risk  ;  serious  haemorrhage  may 
complicate  the  latter. 

Results   of  operation. — In   most   cases   which  have  been 


3SO  INDICATIONS    FOR    OPERATION. 

operated  on  the  results  have  been  quite  satisfactory. 
Ventrofixation  of  the  lobe  appears  to  be  a  satisfactory 
method  of  permanently  anchoring  it. 

Prognosis  without  operation. — If  a  suitable  bandage  or 
apparatus  be  fitted,  the  gastro-intestinal  functions  regulated, 
and  the  general  defects  of  the  circulation  energetically 
combated,  the  symptoms  produced  by  this  condition 
become  supportable  after  a  short  time  as  a  general  rule. 
It  is  only  rarely  that  any  serious  symptoms  (e.g.,  peritonitis) 
are  produced. 

LITERATURE. 

Langenbuch.  Chirurgie  der  Leber  u.  Gallenblase.  2nd  Pt. 
Deut.  Chirurgie.     Stuttgart.      1897. 

Quincke.  Krankheiten  der  Leber.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Therap.     Wien.      1899. 

Kehr.  Leberkrankheiten.  Handbuch  der  prakt.  Chirurgie.  3rd 
Vol.     2nd   Ed.     Bergmann,    Bruns,    u.    Mikulicz.      1903. 

BoTTiCHER.  Ueber  Hepatopexie.  Deut.  Zeitr.  f.  Chir.  Bd.  Ivi., 
p.  252. 

Chevalier.     Technique  de  I'Hepatopexie.     These  de  Paris,  1898. 

Terrier  et  Auvr.w.  IMaladies  du  Foie  et  des  Voies  Biliaires. 
Paris.      1 90 1. 


CHAPTER    XX. 

Diseases    of    the    Spleen. 


353 


Chapter  XX. 

DISEASES   OF    THE   SPLEEN. 

TUMOURS   AND    CHRONIC    HYPERPLASIA   OF    THE 
SPLEEN. 

Etiology. — Chronic  hyperplasia  of  the  spleen  may  be 
due  to  some  "  blood  disease  "  (leucaemia,  pseudoleucaemia), 
or  to  one  of  the  infections  and  intoxications  (syphilis, 
malaria,  alcohol),  or  may  arise  without  recognizable  cause, 
and  is  then  styled  idiopathic.  Enlargement  of  the  spleen 
also  occurs  in  some  affections  of  the  circulatory  system  : 
cardiac  dilatation,  pericardial  adhesions,  and  hepatic 
cirrhosis.  The  etiology  of  splenic  tumours  is  that  of 
tumours  in  general ;  cystic  growths  often  follow  injury, 
or  may  be  of  hydatid  nature. 

Pathological  Anatomy. — Hydatid  cysts  are  sometimes 
of  enormous  size  ;  they  are  usually  unilocular,  rarely 
multilocular,  and  not  uncommonly  suppurate.  The  non- 
parasitic cysts  are  usually  single  ;  their  contents  may  be 
serous,  serohsemorrhagic,  or  haemorrhagic  ;  they  may  be 
of  large  size,  and  may  reach  a  weight  of  lo  kilograms.  Both 
types  of  cystic  growth  may  become  much  adherent  to 
surrounding  parts,  but  this  is  not  the  rule  ;  cysts  are 
proportionately  common  in  "  floating  "  spleen.  The  solid 
growths  are  rare ;  sarcomata,  angiomata,  and  other  forms 
have  been  described  ;  tubercle  and  syphilis  may  give  rise 
to  masses  of  granulation  tissue  formation.  Metastatic 
growths  also  occur.  "  Idiopathic  "  chronic  hyperplasia 
occurs  in  association  with  a  secondary  cirrhosis  of  the 
liver,  the  so-called  Banti's  disease.  Hyperplasia  may  be 
secondary  and  may  be  due  to  hepatic  cirrhosis,  portal 
obstruction,  amyloid  degeneration,  syphilis,  tuberculosis, 
and  chlorosis.  In  all  forms  of  tumour  and  hyperplasia 
the  adhesions  may  be  extensive. 

23 


354  INDICATIONS    FOR    OPERATION    IN 

Clinical  Course. — Tumours  of  the  spleen  may  manifest 
themselves,  according  to  the  nature  of  the  fundamental 
cause,  by  local  symptoms  alone  (pain,  tenderness  on 
pressure,  fullness,  gastric  and  intestinal  disturbances),  or 
by  general  constitutional  signs.  The  parasitic  and  the 
non-parasitic  cysts  occur  with  special  frequency  in  women 
of  middle  age  ;  they  may  be  situated  in  the  body  of  the 
spleen,  or  at  its  lower  pole.  The  presence  of  these  cysts 
does  not,  as  a  rule,  affect  the  general  health  ;  there  is  often 
a  history  of  preceding  trauma.  A  fluctuating  tumour  is 
found,  but  the  hydatid  thrill  is  rarely  to  be  made  out. 
Inflammatory  affections  of  the  pleura  and  lungs  often  occur 
as  complications. 

When  a  solid  growth  is  present  the  surface  of  the  organ 
is  uneven,  and  sometimes  nodules  are  to  be  felt.  Malignant 
growths  develop  rapidly  and  affect  the  general  health. 

Hyperplasia  may  reach  large  dimensions  in  chronic 
malaria,  and  remain  stationary  in  spite  of  energetic  treat- 
ment with  quinine  and  arsenic  preparations  ;  in  this  and  in 
the  hyperplasia  of  leucsmia  and  pseudoleucaemia  there 
is  a  tendency  to  the  occurrence  of  haemorrhages. 

Primary  chronic  hyperplasia  affects  particularly  women 
between  the  ages  of  30  and  40,  and  often  persists  for 
several  years  ;  its  etiology  is  obscure.  The  enlargement 
of  the  organ  is  the  solitary  morbid  phenomenon,  and  is 
the  sole  cause  of  the  existing  symptoms. 

In  all  forms  of  hyperplasia  the  enlargement  is  usually 
uniform,  downwards,  and  to  the  right.  The  organ  moves 
freely  with  respiration,  is  deeply  notched,  and,  as  a  rule, 
there  is  no  intestine  in  front  of  it.  If  the  peritoneal  surface 
becomes  inflamed,  friction  is  often  to  be  heard.  When  the 
enlargement  is  great  the  lower  thoracic  outlet  is  widened, 
the  diaphragm  is  pushed  upwards,  and  the  heart  and  lung 
are  displaced.  The  upper  pole  of  a  splenic  enlargement  can 
often  be  well  seen  on  a  radiograph. 

Diagnosis. — The  diagnosis  of  a  splenic  tumour  rests  on 
its  position,  its  remarkable  mobility  on  respiration,  the 
notches  of  the  lower  border,  the  relations  with  the  intestine, 
its  mobility  in  an  upward  direction  towards  the  left  side 
of  the  epigastrium,  and  its  position  underneath  the  costal 
arches.  The  characters  of  true  new  growths,  cystic  and 
solid,  have  already  been  referred  to.     Examination  of  the 


DISEASES    OF    THE    SPLEEN.  355 

blood  will  reveal  the  true  nature  of  the  hyperplasia  which 
occurs  in  leucaemia,  pseudoleucaemia,  and  malaria,  and 
changes  will  also  be  present  in  the  lymph  glands,  the  liver, 
and  other  organs.  Secondary  hyperplasia  will  be  diagnosed 
when  the  morbid  states  which  have  been  mentioned  as 
causing  this  condition  are  found.  Idiopathic  hyperplasia 
will  be  diagnosed  by  a  process  of  exclusion,  when  none  of 
the  recognized  causes  can  be  discovered.  Banti's  disease 
is  associated  with  anaemia  in  the  first  stages,  and  later  with 
ascites  and  secondary  cirrhosis  of  the  liver. 

INDICATIONS   FOR   OPERATION. 

When  a  cystic  growth  of  the  spleen  is  definitely  diagnosed, 
operation  is  indicated.  The  necessity  for  operation  is 
the  more  urgent  the  more  acute  the  local  symptoms  and 
the  greater  the  rate  of  growth.  Operation  is  urgent  when 
fever  is  associated  with  the  presence  of  a  cyst,  pointing 
to  the  supervention  of  suppuration.  If  the  tumour  is 
stationary,  if  the  local  symptoms  are  slight,  and  if  there  is 
no  fever,  there  is  no  immediate  call  for  surgical  treatment. 

When  a  splenic  enlargement  appears  to  be  due  to  true 
primary  new  growth,  and  is  rapidly  increasing,  splenectomy 
is  indicated.  In  the  case  of  malarial  hyperplasia,  if  the  pain, 
sense  of  weight,  and  other  local  symptoms  are  distressing, 
if  the  enlarged  organ  is  very  mobile,  suggesting  the  possi- 
bility of  torsion  of  the  pedicle,  or  if  other  dangerous 
symptoms  are  induced,  removal  is  advisable  if  medical 
treatment  fails.  The  indications  are  the  same  in  cases  of 
idiopathic  splenomegaly.  When  the  general  health  is 
good  the  presence  of  hyperplasia  alone,  in  the  absence  of  the 
complications  just  mentioned,  cannot  be  considered  a  strict 
indication  for  removal  in  view  of  the  risks  of  operation. 

Contra-indications. — In  cases  of  cystic  tumour  or  of 
multiple  hydatids,  splenectomy  is  not  to  be  advised  when 
there  are  serious  complications  in  other  organs,  or  waxy 
disease. 

Exploratory  puncture  is  dangerous  ;  peritonitis  may  be 
set  up,  which  may  be  fatal  if  the  cyst  contents  are  purulent, 
or  hydatids  may  be  in  this  way  distributed  throughout  the 
peritoneal  cavity. 

Leucaemia  is  an  absolute  contra-indication  to  splenectomy ; 
in  all  the  reported  cases  death  has  resulted  ;    Jordan  has 


3S6  INDICATIONS    FOR    OPERATION    IN 

collected  28,  all  with  the  same  result.  Pseudoleucaemic 
hypertrophy  is  equally  unsuitable  for  operation ;  the  dangers 
are  considerable,  and  the  results  are  ?iil.  In  malarial  cases, 
severe  cachexia,  marked  anaemia,  general  oedema,  a  tendency 
to  haemorrhages,  and  the  probability  of  extensive  adhesions, 
all  contra-indicate  operation.  The  idea  of  operation  will 
not  be  entertained  in  cases  where  the  splenic  enlargement 
is  secondary  to  hepatic  cirrhosis,  or  to  venous  congestion 
from  heart  disease  or  portal  obstruction,  in  waxy  disease, 
tuberculosis,  or  syphilis,  or  where  a  splenic  tumour  is  of 
metastatic  origin. 

Prognosis. — Of  operation.— In  cases  of  cystic  disease  the 
prognosis  is  favourable.  All  the  cases  of  blood  cyst  hitherto 
operated  on,  12  in  number  according  to  Jordan,  have' 
recovered,  the  cases  being  treated  either  by  splenectomy, 
resection,  incision,  or  enucleation.  In  hydatid  disease, 
in  spite  of  the  existence  of  extensive  adhesions  in  several 
cases,  15  out  of  17  recovered  (Jordan).  In  one  case  which 
I  saw  some  years  ago  the  sac  was  punctured  and  iodine 
injected  with  good  result,  but  this  proceeding  must  be 
considered  risky. 

The  five  cases  of  primary  splenic  sarcoma  which  have 
been  operated  on  up  to  the  present,  all  recovered,  one 
permanently.  Extirpation  is  therefore  indicated  in  primary 
malignant  disease,  although  in  some  cases  recurrence  has 
been  rapid. 

Extirpation  of  the  enlarged  malarial  spleen  is  very 
dangerous.  In  117  cases  there  was  a  mortality  of  27  per 
cent  (Fevrier).  If  the  organ  is  mobile  the  risk  is  much 
lessened  ;  in  26  such  cases  there  was  but  one  death  (Bessel- 
Hagen).  It  is  necessary,  therefore,  to  be  very  careful  in 
recommending  operation  ;  the  local  symptoms  are  quickly 
relieved  thereby,  but  the  general  symptoms  improve  only 
slowly. 

The  cases  of  idiopathic  hyperplasia  show  an  operative 
mortality  of  13  per  cent,  two  deaths  in  fifteen  cases. 

There  is  no  physiological  objection  to  removal  of  the 
spleen.  Experience  has  shown  that  the  individual  can 
get  on  quite  well  without  the  organ,  and  that  its  functions 
are  quickly  replaced. 

Without  operation. — Primary  new  growths  and  hydatid 
cysts,   unless   operated    on,    are   eventually   fatal.      Blood 


DISEASES    OF     THE    SPLEEN.  357 

cysts  may  be  dangerous  in  a  high  degree  if  some  com- 
phcation  supervenes,  such  as  suppuration,  torsion,  or 
bursting. 

The  large  malarial  spleen  may  be  a  continual  source  of 
suffering,  may  be  the  cause  of  some  fatal  complication, 
and  may  compromise  the  general  health  by  interfering  with 
digestion.  Chronic  primary  hyperplasia  is  only  dangerous 
when  the  spleen  is  very  mobile,  or  of  very  large  size. 

LITERATURE. 

Jordan.  Die  Exstirpation  der  Milz,  ihre  Indikationen  und 
Resultate.     Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  xi,  H  3. 

Laspeyres.  Indikat.  u.  Result,  totaler  Alilzexstirpationen. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1904. 

LiTTEN.  Die  Krankheiten  der  Milz.  Nothnagel's  Handbucli  d. 
spez.  Eathol.  u.  Therap.     Bd.  viii. 

Bessel-Hagen.  Ein  Beitr.  z.  Milz-Chirurgie.  Arch.  f.  klin. 
Chir.     Bd.  Ixii. 

Simon.  Splenectomie  bei  primaren  sarkom  der  Milz.  Beitr.  z. 
klin.  Chir.     Bd.  xxxv.      1902. 

Braun.  Chirurgie  d.  Milzkrankheiten.  Handbuch  der  prakt. 
Med.  V.  Ebstein-Schwalbe.     Bd.  ii. 

Jonnesco.  La  Splenectomie.  Rev.  de  Chir.  No.  11,  1899,  and 
No.  9,  1900. 

Llobet.     Splenectomie    Totale.     Ibidem.      1900. 

MiCHAiLOWSKY.  Splenectomie  dans  la  Splenomegalie  Malarique. 
Ibidem.      1900. 

Fevrier.  Chirurgie  de  la  Rate.  Rev.  de  Chir.  Oct.,  1901. 
Gaz.  des  Hopit.     Oct.,  1901. 

Bovee.  Splenectomy  for  Congestive  Hypertrophy.  Annals  of 
Surgery,  June,   1900. 

Warren.  The  Surgery  of  the  Spleen.  Annals  of  Surgery,  May, 
1901. 


BANTFS    DISEASE. 

Etiology. — The  etiology  of  this  affection  is  unknown ; 
it  develops  relatively  often  in  young  individuals. 

Pathological  Anatomy. — The  knowledge  of  the 
pathological  anatomy  of  this  condition  is  scanty.  The 
spleen  is  enlarged,  and  this  enlargement  is  chiefly  due  to 
an  overgrowth  of  connective  tissue.  The  liver  exhibits 
the  condition  of  atrophic  cirrhosis,  and  is  sometimes 
divided  up  by  dense  cicatricial  septa.  Marked  athero- 
matous changes  have  been  described  in  the  portal  and 
splenic  veins. 


3S8  INDICATIONS    FOR    OPERATION    IN 

Clinical  Course. — Banti  has  described  three  stages 
of  the  disease.  The  first  stage  is  that  of  gradual  splenic 
enlargement,  associated  with  anaemia.  The  spleen  becomes 
very  large  and  firm,  with  a  smooth  surface.  The  symptoms 
of  anaemia  become  steadily  more  and  more  intense :  palpita- 
tions, lassitude,  oedema  of  the  feet,  epistaxis,  etc.,  but 
they  do  not  necessarily  advance  in  proportion  with  the 
splenic  enlargement.  There  is  a  fall  in  the  number  of  both 
red  and  white  cells,  and  in  the  proportionate  amount  of 
haemoglobin.  There  is  no  fever,  no  enlargement  of 
lymphatic  glands,  no  ascites,  and  no  abnormal  constituent 
in  the  urine.  This  stage  lasts  usually  about  three  to  five 
years,  but  may  be  prolonged  to  ten  years.  The  second 
stage  is  characterized  by  diminution  in  the  quantity  of 
the  urine,  the  appearance  of  bile  pigment  in  the  urine, 
jaundice,  and  gastro-intestinal  disturbance.  It  lasts  for 
several  months.  The  third  stage  is  that  of  secondary 
cirrhosis  of  the  liver,  with  ascites.  The  ascites  sometimes 
disappears  temporarily.  There  are  evening  rises  of 
temperature ;  the  anaemia,  jaundice,  and  tendency  to  haemor- 
rhages become  more  and  more  marked.  Death  occurs 
usually  at  the  latest  about  a  year  after  the  onset  of  the 
third  stage.  Several  times  cholelithiasis  has  been  found 
co-existent. 

Diagnosis. — All  the  other  recognized  causes  of  splenic 
enlargement — malaria,  pseudoleucaemia,  etc. — are  absent, 
and  the  course  of  the  disease  is  sufficiently  characteristic 
to  make  the  diagnosis  clear. 

INDICATIONS   FOR   OPERATION. 

In  several  cases  arrest  of  the  disease  and  even  cure  has 
been  obtained  by  splenectomy.  This  operation  is  indicated 
when  the  size  of  the  spleen  is  such  that  it  is  giving  rise  to 
serious  local  symptoms,  and  when  the  accompanying  liver 
cirrhosis  threatens  danger  to  life  (Jordan).  Operation  may 
be  necessary  on  account  of  the  enlargement  of  the  spleen 
alone  when  it  is  mobile  and  torsion  of  the  pedicle  threatens. 
Inability  to  work  and  the  necessity  of  earning  a  living  will 
influence  the  surgeon  towards  undertaking  operation. 
Early  operation  should  not  be  advised  in  the  absence  of 
the  indications  mentioned,  as  the  course  of  the  disease  is 
uncertain  and  operation  must  always  be  a  serious  risk. 


DISEASES    OF     THE    SPLEEN.  359 

Contra-indications. — Operation  will  be  inadvisable  when 
the  general  condition  is  very  bad.  It  should  not  be  recom- 
mended when  the  general  condition  is  still  good,  anaemia 
absent,  local  symptoms  slight,  and  the  signs  of  hepatic 
disease  insignificant.  Extensive  adhesions  are  a  contra- 
indication ;  their  presence  will  be  diagnosed  when  the 
organ  does  not  move  with  changes  of  position  and  respiration, 
when  during  the  course  of  the  disease  friction  has  been 
heard  over  it,  and  when  it  cannot  be  displaced  by  the 
palpating  band. 

Prognosis.— 0/  operation.— -In  16  cases  collected  by 
Bessel-Hagen,  13  were  cured  by  the  operation ;  the  remaining 
three  died.  The  operation  is,  therefore,  always  attended 
by  risk,  whether  adhesions  are  present  or  not.  Tansini  has 
performed  splenectomy  during  the  third  stage ;  five  months 
later  the  patient  had  all  the  appearance  of  perfect  health. 
In  cases  which  progress  favourably  the  general  condition 
shows  no  permanent  damage.  If  no  operation  is  done 
the  affection  inevitably  terminates  fatally  in  the  third  stage. 

LITERATURE. 

Jordan.  Die  Exstirpation  der  Milz.  Mitteil.  a.  d.  Grenzgebiete 
d.  Med.  u.  Chir.     Bd.  xi.,  H.  3. 

Senator.  Ueber  Anaemia  Splenica  mit  Ascites.  Berl.  klin. 
Wochens.,   No.   46,    1901. 

FiCHTEUR.  Zur  Kenntniss  der  Banti'schen  Krankheit.  Miinch. 
med.  Wochens.,  No.   11,  1903. 

Pribram,  Chiari.  Banti'sche  Krankheit.  Prag.  med.  Wochens., 
Nos.  2  and  24.      1902. 

Laspeyres.  Total  Milzexstirpation.  Centralb.  f.  d.  Grenzgebiete 
d.  Med.  u.  Chir.,  1904. 

Tansini.  Die  Splenectomie  bei  Banti'schen  Krankheit.  Arch, 
f.  klin.  Chir.     Bd.  Ixvii.      1902. 

Harris  and  Herzog.  Splenectomy  in  Splenic  Anaemia.  Annals 
of  Surgery,  July,   1901. 

Fevrier.     Chirurgie  de  la  Rate.     Rev.  de  Chir.,  Oct.,   1901. 


FLOATING    SPLEEN. 

Etiology.  —  The  most  important  etiological  factors  are 
congenital  anomalies,  such  as  abnormal  length  of  the  liga- 
ments, and  acquired  lengthening  of  the  ligaments  by  trauma 
or  by  the  increased  weight  of  the  enlarged  organ.  Such 
enlargement  is  most  commonly  due  to  malaria,  leucaemia, 


36o  INDICATIONS    FOR    OPERATION    IN 

or^pseudoleucaemia.  The  non-hypertrophic  floating  spleen 
is  most  common  in  women. 

Pathological  Anatomy. — The  dislocated  spleen  has 
been  found  in  all  the  regions  of  the  abdomen.  Most 
commonly  it  is  in  the  left  hypogastrium  ;  in  many  cases 
the  position  of  the  hilum  is  much  modified.  Such  a 
dislocated  organ  is  often  hypertrophied,  and  sometimes 
profoundly  altered  in  structure,  by  torsion  of  its  pedicle  ; 
it  may  be  atrophied  and  shrunken,  or  sometimes  gangrenous  ; 
in  the  latter  case  the  afferent  and  efferent  vessels  are 
obstructed  or  entirely  obliterated.  The  pedicle  may  have 
more  than  one  complete  turn.  A  dislocated  spleen  may 
be  fixed  by  adhesions  in  its  abnormal  position. 

Clinical  Signs  — A  movable  abdominal  tumour  is  found, 
and  the  spleen  is  absent  from  its  nonnal  position.  Unless  it 
is  fixed  by  adhesions  it  can  be  replaced  in  its  normal  situ- 
ation. There  may  be  no  symptoms  ;  but  often  the  patient 
complains  of  vague  troubles,  feelings  of  distension,  nausea, 
dyspepsia,  headache  ;  sometimes  there  are  neuralgic  pains, 
and  even  paralyses  of  the  legs  or  bladder  tenesmus.  Cases 
presenting  symptoms  of  intestinal  obstruction  have  often 
been  described.     Frequently  there  is  general  enteroptosis. 

Diagnosis. — If  the  movable  tumour  has  the  characteristic 
shape  of  the  spleen,  with  the  notch  of  the  internal  border, 
and  the  hilum  containing  pulsating  vessels ;  if  percussion 
is  tympanitic  over  the  normal  splenic  area  and  changes 
when  the  tumour  is  replaced,  there  can  be  no  doubt  as  to 
the  diagnosis.  The  condition  is  often  mistaken  for  floating 
kidney  and  movable  ovarian  tumours,  and  sometimes  for 
tumours  of  other  abdominal  organs.  The  outline  of  the 
tumour  is  important,  and  the  examination  of  the  loin  for 
the  kidney,  and  of  the  pelvis  for  connections  with  the 
generative  organs.  Friction  over  the  tumour  indicates 
perisplenitis.  Torsion  of  the  pedicle  must  be  diagnosed  if 
the  patient  has  a  sudden  attack  of  acute  pain,  associated 
with  enlargement  and  exquisite  tenderness  of  the  splenic 
tumour,'if  the  latter  is  noted  to  have  altered  its  position,  and 
symptoms  of  early  peritonitis  and  of  collapse  supervene. 

INDICATIONS   FOR   OPERATION. 

If,  in  spite  of  internal  treatment  prescribed  with  a  view 
to  lessening  the  size  of  the  spleen,  and  in  spite  of  the  wearing 


DISEASES    OF     THE    SPLEEN.  361 

of  suitable  bandages,  the  pains  persist  to  such  an  intense 
degree  that  hfe  is  made  miserable,  or  if  the  spleen  is  of  such 
a  size  that  in  itself  it  constitutes  a  danger  to  life,  then  opera- 
tion is  advisable. 

If  torsion  of  the  pedicle  appears  probable,  extirpation 
should  be  performed  with  a  view  to  avoiding  this  very 
dangerous  complication.  Some  surgeons  consider  that  a 
movable  spleen,  whether  enlarged  or  not,  should  be  extir- 
pated in  view  of  the  possibility  of  torsion  of  the  pedicle. 
This  radical  advice  has  not,  however,  at  present  many 
supporters  ;  statistics  show  that  the  operation  is  not  free 
from  risk,  and,  on  the  other  hand,  torsion  is  very  unusual 
when  the  organ  is  of  normal  size.  Fixation  of  the  spleen 
by  suture  has  been  often  recommended  for  such  cases  on 
account  of  the  smaller  risk,  but  even  this  operation  should 
not  be  recommended  for  simple  mobility  unless  the  condition 
is  giving  rise  to  marked  symptoms. 

Contra-indications. — If  the  patient's  general  health  is 
very  bad,  or  if  there  are  lesions  in  other  organs,  operation 
will  not  be  advisable  ;  leucaemia  or  pseudoleucaemia  are 
absolute  contra-indications.  Even  when  the  pains  and 
other  local  disturbances  are  intense,  operation  should  not 
be  done  if  they  are  present  only  for  short  periods  and  if 
the  spleen  is  of  normal  size,  unless  torsion  of  the  pedicle 
is  suspected.  Such  symptoms  may  disappear  entirely  for 
a  long  time  after  reposition  of  the  organ.  Seven  years  ago 
I  had  under  my  care  a  young  girl  with  floating  spleen  who 
had  attacks  of  intense  pain  of  short  duration  ;  these 
disappeared  after  the  application  of  a  bandage.  Although 
she  has  been  without  the  bandage  now  for  some  five  years, 
she  has  had  no  further  attacks. 

When  the  tumour  is  of  very  large  size  the  danger  of 
operation  is  great,  and  in  such  cases  extirpation  is  only 
exceptionally  indicated.  Pregnancy  does  not  absolutely 
contra-indicate  extirpation. 

Prognosis. — Risks  of  operation. — Up  to  1900,  92  cases  of 
floating  spleen  (of  different  etiology,  hypertrophied,  and 
also  of  normal  size)  had  been  treated  by  extirpation  (Bessel- 
Hagen).  Of  these  17  died  from  the  operation.  The  opera- 
tive mortality  is  very  high  in  cases  of  torsion  of  the  pedicle, 
on  account  of  the  serious  nature  of  the  condition.  The 
prognosis  is  relatively  good  in  cases  of  malarial  enlargement 


362  INDICATIONS    FOR    OPERATION    IN 

without  torsion  (i  fatality  in  15  cases),  and  in  simple  hyper- 
trophy (2  deaths  in  28  cases). 

Results  of  operation. —  Almost  all  cases  regain  their 
capacity  for  work  in  a  short  time,  and  completely  lose  their 
pains. 

Withoiit  operation. — In  many  cases  mobility  of  the  spleen 
is  well  tolerated  without  symptoms  or  with  only  slight 
disturbances.  If  torsion  of  the  pedicle  occurs,  necrosis 
follows  and  death  results  unless  operation  is  done. 

LITERATURE. 

LiTTEN.  Die  Krankheiten  der  'SlWz.  Nothnagel's  Handbuch 
d.  spez.  Pathol,  u.  Therapie.     Wien.      1898. 

Bessel-H.\gen.  Ein  Beitrag  zur  Milz  Chirurgie.  Arch.  f.  kUn. 
Chir.      Bd.  Ixii,  H.  i. 

Laspeyres.  Indikationen  u.  Resultate  totaler  Milzexstu-pation. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1904. 

Stierlix.  Ueber  die  chir.  Behandlung  der  Wandermilz.  Zeit.  f. 
Chir.     Bd.  xlv. 

ScHW'ARTZ.  Alilzexstirpation.  Wien.  klin.  Wochens.,  No.  52. 
1900  ;     and  Centr.   f.   Gynak.     Bd.   xxiii.,   No.    31. 

Christomanos.  Ein  Fall  von  vollstandiger  Milznekrose.  Beitr. 
z.  Path.  Anat.     Bd.  xxiv,  p.  519. 

Fevrier.     Chirurgie  de  la  Rate.     Rev.  de  Chir.     Oct.,    1901. 

JoNNESco.  La  Splenectomie.  Rev.  de  Chir.,  No.  11,  1894,  and 
No.  9,  1901. 

Chandeleux.  Splenectomi'i  pour  Rate  Mobile.  Lyon  Medicale. 
No.  13,  1900. 

Scott  Stone.  Splenectomy  for  Floating  Spleen.  Annals  of 
Surgery,  Sept.,   1899. 

W.\rren.  The  Surgerj-  of  the  Spleen.  Annals  of  Surgery,  May, 
1 90 1 . 


RUPTURE    OF    THE    SPLEEN. 

Etiology? — The  spleen  is  ruptured  by  injury,  and  the 
accident  may  happen  to  the  normal  or  the  enlarged  organ. 
When  altered  by  disease,  slight  injury  may  be  sufficient 
to  cause  rupture,  and  this  is  especially  true  of  the  malarial 
spleen. 

Pathological  Anatomy. — Rupture  of  the  spleen  may 
be  the  sole  result  of  an  abdominal  trauma.  Extravasation 
of  blood  takes  place  into  the  abdominal  cavity  in  large 
quantity,  and  collects  in  its  most  dependent  parts,  or  may 
be  limited  by  adhesions.     In  one  of  my  cases  an  extravasa- 


DISEASES    OF    THE    SPLEEN.  363 

tion  limited  by  adhesions  around  the  spleen  simulated   an 
enormous  fixed  splenic  tumour. 

Clinical  Course  and  Diagnosis. — The  symptoms  of 
rupture  of  the  spleen  are  those  of  serious  internal  haemor- 
rhage. First  excruciating  pain,  pallor,  vertigo,  vomiting, 
and  syncope ;  then  the  pulse  becomes  small  and  rapid,  the 
abdomen  becomes  distended,  and  there  are  signs  of  fluid, 
either  free  in  the  peritoneal  cavity  or  confined  to  the  splenic 
area.  If  the  size  of  the  hypertrophied  spleen  is  already 
known  before  the  accident,  its  diminution  is  an  important 
aid  in  diagnosis.  The  diagnosis  is,  as  a  matter  of  fact, 
only  exceptionally  possible,  because  internal  haemorrhage 
from  other  abdominal  organs  produces  the  same  symptoms, 
but  it  is  probable  when  the  fluid  signs  extend  from  the  left 
iliac  fossa  towards  the  right,  and  the  previously  enlarged 
spleen  diminishes  in  size. 

INDICATIONS   FOR   OPERATION. 

When  the  signs  and  symptoms  point  to  internal 
haemorrhage  from  splenic  rupture,  the  abdomen  must  be 
opened  at  once  to  discover  the  source  of  the  haemorrhage 
and  remove  the  spleen. 

Prognosis. — Risks  and  prospects  of  the  operation. — 
According  to  Jordan,  in  29  cases  operated  on  between 
1893  and  1903,  life  has  been  saved  by  splenectomy. 
Considering  the  gravity  of  the  affection  the  operation 
must,  of  course,  be  considered  a  serious  undertaking.  The 
prognosis  by  "  expectant  "  treatment  is  exceedingly  bad  ; 
the  great  majority  of  cases  so  treated  die. 

LITERATURE. 

LiTTEN.  Krankheiten  der  Milz.  Nothnagel's  Handbuch  d.  spez. 
PathoL  u.   Therap.     Bd.  viii       1898. 

Jordan.  Die  Exstirpation  der  Milz.,  etc.  Mitteil.  a.  d.  Grenzge- 
biete  d.  Med.  u.  Chir.     Bd.  xi,  H.  3. 

Laspeyres.  Indikat.  u.  Result.  Totaler  Milzexstirpation. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1904. 

Berger.  Die  Verletzungen  der  Milz  u.  ihre  chirurg.  Behandlung. 
Arch.  f.  klin.  Chir.     Bd.  Ixviii.      1902. 

Ballancb.  On  Splenectomy  for  Rupture  without  External 
Wound.     Practitioner,  April,   1898. 

LoisoN.  Ruptures  Traumatiques  de  la  Rate  dans  les  Contusions 
de  I'Abdomen.     Bullet,  de  la  Soc.  de  Chirurg.  de  Paris,     xxvii,  p.  40. 

M.\uclaire.  Rupture  de  la  Rate.  Ibidem.  Nos.  4  and  24, 
1901. 


364  INDICATIONS    FOR    OPERATION    IN 

ABSCESS    OF    THE    SPLEEN. 

Etiology. — Splenic  abscess  is  usually  due  to  injury, 
to  suppuration  in  the  neighbourhood  of  the  spleen,  or  to 
embolus  in  ulcerative  endocarditis.  It  occurs  exceptionally 
in  cases  of  recurrent  fever  and  enteric. 

Pathological  Anatomy. — Splenic  abscesses  may  be 
central  or  peripheral,  solitary  or  multiple.  The  size  varies 
enormously  up  to  that  of  a  child's  head.  Sometimes  the 
suppuration  spreads  beyond  the  spleen,  and  a  subphrenic 
abscess  is  formed,  and  in  such  a  case  the  spleen  may  be 
suspended  in  the  middle  of  the  abscess  cavity.  Dense 
adhesions  may  be  formed  to  surrounding  structures.  The 
pus  may  be  sterile. 

Clinical  Signs  and  Diagnosis. — The  diagnosis  of  this 
rare  affection  is  only  occasionally  possible.  In  a  case  of 
ulcerative  endocarditis  or  enteric  fever,  if  the  patient 
complains  of  severe  pain  in  the  splenic  region  radiating  to 
the  left  shoulder,  if  there  are  perisplenic  friction,  rigors,  and 
fever  which  becomes  remittent  after  a  time,  the  diagnosis 
will  be  clear.  If  a  liuctuating  area  is  discovered  in  an 
enlarged  spleen,  exploratory  puncture  will  clear  up  the 
diagnosis,  and  if  pus  is  found  laparotomv  must  be  done 
forthwith.  Sometimes  the  pus  makes  its  way  into  a 
neighbouring  hollow  viscus,  sometimes  into  the  abdominal 
cavity  or  the  lung,  and  the  size  of  the  enlarged  organ  will 
then  markedl}^  diminish.  Among  several  cases  which 
have  been  under  my  care,  the  diagnosis  was  made  in  one 
only  by  exploratory  puncture.  Most  frequently  I  have 
seen  it  in  cases  of  endocarditis,  and  once  in  a  case  of  pyle- 
phlebitis secondary  to  disease  of  the  appendix. 

INDICATIONS   FOR   OPERATION. 

If  the  diagnosis  is  certain  operation  is  absolutely 
indicated.  The  operation  will  consist  either  of  puncture, 
which  is  dangerous,  on  account  of  the  risk  of  infecting  the 
peritoneum,  or  incision,  or  extirpation  when  the  spleen  is 
bathed  in  pus  and  free  from  adhesions. 

The  only  contra-indications  are  the  presence  of  multiple 
suppurative  foci  in  the  kidneys  and  elsewhere,  and  such  a 
state  of  general  weakness  that  the  patient  will  stand  no 
operation  whatever. 


DISEASES     OF     THE     SPLEEN 


365 


Prognosis.— Splenic  abscess  is  usually  fatal.  It  may 
become  encapsuled,  and  after  long  latency  recrudescence 
may  take  place.  The  case  to  which  I  have  alluded  was  that 
of  a  woman  who  had  had  puerperal  fever  some  years 
previously ;  when  seen  she  complained  of  severe  pain  in  the 
region  of  the  spleen,  but  had  no  fever. 

Laspeyres  has  collected  11  cases  which  were  submitted 
to  operation  ;  recovery  took  place  in  all.  It  is  probable 
that  there  have  been  fatal  cases  which  have  not  been 
published. 

LITERATURE. 

LiTTEN.     Die    Krankheiten  der  Milz.     Nothnagel's  Handbuch  d 
spez.  Pathol,  u.  Therap.     Bd.  viii. 

Laspeyres.  Indik.  u.  Result.  Totaler  Milzexstirpationen. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1904. 

Kehr.  Chirurgie  der  Milz.  Handbuch  der  prakt.  Chir.  Mikulicz, 
Bruns,  u.  Bergmann.     Bd.  iii. 

Bessel-Hagen.  Ein  Beitrag  zur  Milzchirurgie.  Arch,  f  khn 
Chir.     Bd.  Ixii,  H.  i. 

Murphy.  Note  on  Successful  Splenectomy.  Brit.  Med.  Jour 
Nov.  3,  1894. 

Fevrier.  Chir.  de  la  Rate.  Rev.  de  Chir.,  1901  ;  and  Gaz. 
des  Hopit.,  Oct.,    1901. 


CHAPTER    XXL 
Diseases    of    the    Pancreas. 


369 


Chapter    XXI. 
DISEASES     OF     THE    PANCREAS. 

INFLAMMATION   AND   NECROSIS. 

Etiology. — Pancreatitis  may  be  secondary  to  ulcerative 
processes  in  the  stomach  and  duodenum,  or  may  be  due  to 
injury,  spontaneous  haemorrhage,  cholelithiasis,  or  pan- 
creatic calculus.  Fat  people  are  predisposed  to  pancreatic 
necrosis. 

Pathological  Anatomy. — Suppurative,  acute,  haemor- 
rhagic,  and  necrotic  pancreatitis  have  been  distinguished 
pathologically  ;  these  are  not  distinct  types,  but  pass  into 
one  another.  Frequently  small  foci  of  fat  necrosis  are 
found  distributed  throughout  the  peritoneal  cavity.  As  a 
result  of  inflammation  and  necrosis,  large  purulent  and 
septic  collections  may  form,  surrounding  the  necrosed 
gland,  and  often  encapsuled  by  extensive  peritoneal 
adhesions  ;  these  abscesses  usually  occupy  the  upper  part 
of  the  abdomen.  Many  cases  are  complicated  by  infective 
cholangitis  of  long  standing,  not  uncommonly  with  im- 
paction of  a  calculus  in  the  ampulla  of  Vater,  and  regurgi- 
tation of  infected  bile  from  the  common  bile-duct  into  the 
pancreatic  duct. 

Clinical  Course. — Mayo  Robson  has  distinguished  three 
clinical  types  of  pancreatitis  :  the  acute,  the  subacute,  and 
the  chronic.  In  corpulent  individuals  the  disease  often  has 
an  acute  and  sudden  onset.  It  commences  with  severe  pain 
in  the  epigastric  region,  vomiting,  nausea,  and  peritoneal 
symptoms.  Meteorism  rapidly  develops,  and  diffuse 
tenderness  of  the  abdomen,  with  obstruction  of  fseces  and 
flatus.  The  pulse  is  small  and  rapid,  and  the  patient 
usually  much  collapsed  ;    fever  is  often  absent. 

If    the    patient    does    not    die    early    from    shock,    an 

24 


370  INDICATIONS    FOR    OPERATION    IN 

inflammatory  swelling  develops  gradually  in  the  upper 
part  of  the  abdomen,  accompanied  by  pronounced  loss 
of  strength  and  remittent  fever.  If  the  stomach  and 
colon  are  distended  with  air,  the  physical  signs  will  show 
that  the  swelling  lies  behind  both.  Enemata  will  often 
empty  the  bowel,  and  later  even  diarrhoea  may  appear. 
Sometimes  the  stools  are  fatty,  and  may  contain  undigested 
muscle  fibres  ;  in  several  cases  glycosuria  has  been  present. 
There  is  persistent  nausea  and  vomiting. 

The  skin  is  sometimes  of  a  greyish  brown  colour. 
Jaundice  is  often  present,  particularly  when  the  pancreatitis 
is  of  the  chronic  type,  and  in  this  form  the  enlarged  head 
of  the  pancreas  may  be  felt  as  a  hard  tumour.  The  rapid 
wasting  causes  a  suspicion  of  new  growth,  and  the  attacks 
may  resemble  gall-stone  colic  in  such  a  way  that  this 
condition  may  be  diagnosed.  As  has  already  been  stated, 
the  disease  is  often  secondary  to  impaction  of  a  stone  in 
Vater's  ampulla.  The  gall-bladder  is  frequently  distended 
and  palpable. 

Diagnosis. — The  diagnosis  is  often  very  difficult,  and 
in  the  early  stages  of  acute  pancreatitis  it  cannot  as  a 
rule  be  made  with  certainty.  In .  most  cases  the  condition 
has  been  diagnosed  as  intestinal  obstruction  or  perforative 
peritonitis.  Later  the  difficulties  are  less  when  there  is 
a  history  of  a  sudden  onset,  with  pain  in  the  epigastrium, 
vomiting,  constipation,  and  distension,  when  the  tempera- 
ture is  raised  and  a  swelling  is  present  in  the  characteristic 
position.  If  the  stomach  and  colon  be  distended  and  are 
found  to  lie  in  front  of  the  tumour,  the  latter  cannot  belong 
to  liver,  gall-bladder,  or  spleen.  Confusion  must  sometimes 
occur  with  obstruction,  perforative  peritonitis,  perinephritis, 
or  a  burrowing  abscess,  but  this  will  not  often  happen  if 
the  points  mentioned  are  carefully  considered. 

In  the  case  of  a  corpulent  woman  of  middle  age  who  had 
been  under  the  care  of  Ewald  and  myself  for  some  years, 
severe  peritoneal  symptoms  suddenly  appeared,  and  were 
followed  by  the  development  of  a  large  inflammatory  and 
apparently  retroperitoneal  swelling  in  the  left  hypochon- 
drium.  Seeing  that  the  swelling  extended  across  the 
middle  line  and  was  confined  to  the  upper  part  of  the 
abdomen,  it  was  thought  that  we  had  to  do  with  an  inflam- 
matory    affection    of     the    pancreas    (?    necrosis).       The 


DISEASES     OF     THE     PANCREAS.  371 

abscess  was  opened,  and  throughout  the  peritoneum  spots 
of  fat  necrosis  were  found.     Recovery  took  place. 

Chronic  pancreatitis  is  specially  frequently  mistaken 
for  carcinoma  ;  the  head  of  the  organ  may  be  transformed 
into  a  large  hard  nodular  mass,  which,  even  on  operation, 
cannot  be  distinguished  from  cancer. 

INDICATIONS   FOR   OPERATION. 

When  a  diagnosis  of  subacute  pancreatitis  is  made,  and 
even  when  the  signs  and  symptoms  point  only  to  the  proba- 
bility of  the  condition,  operation  should  be  undertaken  unless 
the  general  condition  is  extremely  bad,  particularly  if  there 
is  a  palpable  inflammatory  swelling  in  the  upper  abdomen. 
The  abscess  will  be  opened  through  an  abdominal  wound, 
and  drained.  When  chronic  pancreatitis  is  suspected, 
and  serious  symptoms,  such  as  intense  jaundice,  rapid 
wasting,  and  severe  pain,  are  present,  operation  is  advised 
by  many.  Laparotomy  is  performed,  and  if  a  calculus  is 
found  it  is  removed  and  the  pancreatic  duct  drained,  or  a 
biliary  fistula  is  established,  or  cholecystenterostomy  into 
the  duodenum. 

In  acute  pancreatitis  many  surgeons  are  in  favour  of 
operation,  either  simple  opening  of  the  abdomen  and 
drainage,  or  exposure  and  incision  of  the  pancreas  ;  others 
are  opposed  to  this  practice.  The  decision  as  to  operation 
depends  almost  always  on  the  surgeon,  not  on  the  practi- 
tioner or  physician,  for  most  cases  are  operated  on  under  an 
erroneous  diagnosis  or  as  exploratory  laparotomies. 

Contra-indications. — In  the  first  stage,  when  this  is 
recognized,  operation  is  considered  inadvisable  by  many 
surgeons,  for  most  of  the  patients  have  died  of  shock  either 
during  or  soon  after  the  operation.  Whilst  symptoms  of 
severe  peritoneal  irritation  (universal  meteorism,  frequent 
vomiting,  obstruction  to  faeces  and  flatus)  are  present, 
and  the  patient  is  much  collapsed,  many  surgeons  think  it 
well  to  suspend  operation,  but  others,  Mikulicz  for  example, 
advise  operation  even  under  these  conditions. 

Prognosis. — Results  of  operation. — In  seventy-five  cases 
of  acute  pancreatitis  operated  on  early  and  late,  twenty- 
nine  recovered ;  of  the  latter  twenty-five  belonged  to  a  group 
of  thirty-seven  cases,  in  which  the  pancreas  itself  was  dealt 
with,   whilst   four  only   recovered  out   of    forty-one   cases 


372  INDICATIONS    FOR    OPERATION    IN 

in  which  the  pancreas  was  left  untouched  (v.  MikuHcz).  A 
considerable  number  of  deaths  have  occurred  immediately 
after  the  operation  ;  others  have  taken  place  at  variable 
periods  from  profuse  suppuration  or  secondary  haemorrhages. 
Sometimes  a  pancreatic  fistula  forms,  but  this  almost  always 
heals.  According  to  Mikulicz  the  prognosis  of  operation 
in  chronic  pancreatitis  is  good ;  of  thirty-eight  cases 
thirty-three  recovered  and  five  died.  Truhart  has  collected 
seventeen  cases  of  recovery  after  operation,  in  cases  with 
multiple  abdominal  fat  necrosis. 

Without  operation. — In  subacute  pancreatitis  or  necrosis 
death  usually  occurs  with  progressive  marasmus.  Either 
universal  peritonitis  develops,  or  venous  thrombosis,  or 
abscess  of  liver  or  spleen,  or  a  subphrenic  abscess  may 
form  and  involve  the  pleura  and  lung  by  penetrating 
the  diaphragm.  In  rare  instances  spontaneous  recovery 
has  taken  place  in  cases  with  multiple  fat  necrosis 
after  elimination  of  the  necrotic  pancreas  per  rectum, 
or  the  spontaneous  rupture  of  an  abscess  through 
the  abdominal  wall.  Truhart  has  collected  eight  such 
cases. 

Chronic  pancreatitis  in  many  cases  causes  death  from 
cachexia  and  cholaemia  by  compression  of  the  bile-ducts. 
I  can  call  to  mind  a  not  inconsiderable  number  of  such 
cases  which  I  have  had  the  opportunity  of  examining 
post  mortem. 

LITERATURE. 

KoRTE.  Die  chirurgischen  Krankheiten  des  Pankreas.  Deut. 
Chir.     Stuttgart:    Enke.      1898. 

OsER.  Krankheiten  des  Pankreas.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Therap.      1898. 

H.  Truhart.  Pankreas-Pathologie.  Teil  i.  Multiple  abdominelle 
Fettgewebsnekrose.     Wiesbaden:    F.  Bergmann.      1902. 

Takayasu.  Beitr.  z.  Chir.  d.  Pankreas.  Mitteil.  a.  d.  Grenzge- 
biete  d.  Med.  u.  Chir.     Bd.  iii. 

v.  Mikulicz.  Ueber  den  Heutigen  Stand  der  Chirurgie  des 
Pankreas.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.  Bd.  xii, 
Hf.  I. 

Mayo  Robsok  and  Moynihan.  Diseases  of  the  Pancreas  and 
their  Surgical  Treatment.      1903. 

Newton  Pitt.  Five  Cases  of  Acute  Pancreatitis.  Trans.  Qin. 
Soc,  London.      1899. 

Page.  Traitement  des  Pancreatites  Suppurees  et  Gangreneuses. 
These  de  Bordeaux.      1898. 


DISEASES    OF     THE    PANCREAS.  373 

Faure.  Pancreatite  Suppuree.  Bullet,  et  Mem.  de  la  Soc.  de 
Chirurgie  de  Paris,  Dec.  8,   1899. 

M.  Heger.  La  Chirurgie  du  Pancreas.  Jour.  Med.  de  Bruxelles, 
5  annee,  No.  ;i^. 

PANCREATIC    CALCULUS. 

Etiology. — Nothing  is  known  as  to  tlie  nature  of  the 
processes  which  give  rise  to  the  formation  of  pancreatic 
calcuh,  except  that  anything  which  causes  stagnation  of 
secretion  appears  to  conduce  to  their  formation.  They 
occur  most  frequently  in  men,  between  the  ages  of  thirty-five 
and  forty-five. 

Pathological  Anatomy. — As  a  rule  more  than  one  stone 
is  found,  and  in  some  cases  the  canal  of  Wursung  is'  encrusted. 
The  place  of  lodgement  is  frequently  in  the  neighbourhood 
of  the  duodenal  opening  ;  a  calculus  may  reach  the  size 
of  a  cherry,  the  usual  composition  is  calcium  phosphate 
or  carbonate.  Frequently  there  are  inflammatory  changes 
in  the  pancreatic  parenchyma  and  ducts,  and  abscesses 
may  result  therefrom. 

Clinical  Course. — The  commonest  symptom  is  the 
occurrence  of  severe  attacks  of  colic,  resembling  biliary 
colic  and  localized  in  the  epigastrium.  Often  the  pain 
radiates  markedly  to  the  left.  Greyish- white  calculi  of 
the  characteristic  composition  are  sometimes  passed  after 
an  attack.  Intense  ptyalism  has  often  been  noted  during 
an  attack ;  late  symptoms  sometimes  found  are  diarrhoea, 
with  the  discharge  of  quantities  of  unchanged  muscle  fibre 
and  abnormal  amounts  of  unabsorbed  fat,  and  diabetes. 
There  is  sometimes  jaundice  during  or  after  an  attack  ; 
fever  is  unusual. 

The  diagnosis  is  based  on  the  occurrence  of  attacks  of 
colic,  followed  by  the  evacuation  of  characteristic  concretions 
and  sometimes  by  slight  jaundice.  Later  symptoms  which 
may  appear  are  glycosuria,  steatorrhoea,  and  disturbances  of 
digestion.  At  these  late  stages  the  diagnosis  is  only 
possible  in  rare  cases. 

INDICATIONS  FOR  OPERATION. 

According  to  v.  Mikulicz,  pancreatic  calculi  rarely  give 
rise  to  characteristic  symptoms  unless  they  are  discharged 
in  tlie  fa;;ces,  and  it  is  only  the  secondary  changes  produced 


374  INDICATIONS     FOR     OPERATION     IN 

by  them  which,  as  a  rule,  come  to  the  notice  of  the  surgeon. 
These  changes  are  the  result  of  obstruction  of  the  pancreatic 
duct  and  its  branches,  and  eventuate  in  a  chronic  or  sub- 
acute pancreatitis.  Surgical  intervention  finds  an  indication 
only  in  the  symptoms  produced  by  this  condition  of 
pancreatitis,  but  in  all  cases  of  this  nature  the  possibility 
of  the  presence  of  a  calculus  should  be  borne  in  mind. 
The  indications  for  operation  will  therefore  depend  upon 
the  appearance  of  a  palpable  inflammatory  swelling  in  the 
position  of  the  pancreas,  accompanied  by  pain,  fever,  and 
other  pronounced  symptoms. 

Contra-indications. — The  existence  of  colic  without 
discharge  of  characteristic  calculi,  and  without  the  appear- 
ance of  a  swelling  in  the  position  of  the  pancreas,  leaves  the 
diagnosis  so  uncertain  that  operation  should  not  be  recom- 
mended. If  calculi  are  discharged  and  the  symptoms  are 
relatively  slight,  operation  will  again  be  inadvisable. 

Prognosis. — With  regard  to  the  risks  of  operation  and 
the  prognosis  as  to  recurrence  if  a  stone  is  successfully 
removed,  clinical  experience  is  not  sufficiently  extensive 
for  the  formulating  of  a  definite  statement.  Of  three  cases 
operated  on  two  died  from  the  operation,  the  third  being 
cured  by  removal  of  a  calculus  through  the  duodenum. 

LITERATURE. 

G.  Zesas.  Beitr.  z.  Diagnose  der  Lithiasis  Pancreatica.  Centralb. 
f.  d.  Grenzgebiete  der  Aled.  u.  Chir.,  21,  1903. 

V.  Mikulicz.  Ueber  der  Heutigen  Stand  der  Chirurgie  des  Pan- 
creas.     Mitteil.  a.  d.  Grenzgebiete   d.  Med.  u.  Chir.     Bd.  xii,  Hf.    i. 

Mayo  Robson  and  Moynihan.  Diseases  of  the  Pancreas  and 
their  Surgical  Treatment.     Saunders  &  Co.      1903. 

KoRTE.  Die  chirurgischen  Krankheiten  des  Pancreas.  Deut. 
Chir.     Stuttgart.      1898. 

OsER.  Pankreaskrankheiten.  Nothnagel's  Handbuch  d.  spez. 
Pathol,  u.  Therap.    Wien.      1898. 

M.  Heger.  La  Chirurgie  du  Pancreas.  Jour.  Med.  de  Bruxelles. 
5  annee,  No.  33. 

Movnihan.     Lancet,  August,  1902. 


PANCREATIC    CYSTS. 

Etiology. — Injury  and  chronic  interstitial  inflammatory 
affections  appear  to  be  of  considerable  etiological  importance. 
Individuals  of  middle  age  are  most  frequently  affected. 


DISEASES     OF     THE    PANCREAS.  375 

Pathological  Anatomy. — These  cysts  may  be  of  great 
size  and  contain  up  to  20  litres  of  fluid.  They  grow 
forwards,  as  a  rule,  in  the  bursa  omentalis,  between  the 
stomach  and  the  transverse  colon  ;  more  rarely  they 
present  above  the  lesser  curvature  or  below  the  transverse 
colon.  They  are  usually  sessile,  exceptionally  pedunculated. 
They  contain  a  colourless  or  dark-coloured  fluid,  in  which 
the  pancreatic  ferments  are  usually  demonstrable. 

Clinical  Signs. — Symptoms  which  are  often  present 
early  are  epigastric  pain,  vomiting,  rapid  wasting,  and 
jaundice.  The  rounded,  elastic,  and  generally  immobile 
cyst  is  more  usually  in  the  middle  line  than  laterally  in 
the  hypochondrium.  Glycosuria  or  fatty  stools  are  rarely 
found,  and  the  intestinal  digestion  is  as  a  rule 
unaffected.  The  growth  is  usually  very  gradual ;  periodic 
enlargement  and  dwindling  have  often  been  noted. 

Diagnosis. — The  diagnosis  will  be  based  on  a  history 
of  trauma  or  chronic  inflammation,  on  the  presence  of 
symptoms  due  to  pressure  on  the  stomach  and  intestine, 
and  on  the  localization  of  the  tumour  and  its  relation  to 
these  organs.  When  the  stomach  is  distended  the  cyst  is  in 
many  cases  partially  covered,  in  most  cases  from  above  down- 
wards, more  rarely  from  below  upwards.  Distension  of  the 
colon  will  show  that  the  cyst  lies  above  it  when  it  occupies 
the  usual  position  between  this  and  the  stomach.  Explora- 
tory puncture  is  dangerous  and  not  to  be  recommended. 

Differential  diagnosis  from  other  cystic  abdominal 
affections  is  often  very  difficult.  In  even  a  very  large 
ovarian  cyst  the  stomach  is  not  found  overlying,  and  when 
an  ovarian  cyst  is  situated  high  the  uterus  is  dragged  up. 
Cysts  of  the  liver  are  never  covered  by  the  distended  or 
inflated  stomach.  The  enlarged  gall-bladder  hardly  ever 
has  intestine  in  front  of  it ;  cysts  of  the  head  of  the  pancreas 
are  almost  always  overlaid  in  part ;  however,  in  one  case 
of  pancreatic  cyst,  verified  by  operation,  I  diagnosed 
a  gall-bladder  affection  on  account  of  the  extreme  mobility 
of  the  cyst  and  the  history  of  the  case.  Splenic  cysts  are 
also  to  be  differentiated  by  the  absence  of  stomach  or 
intestine  in  front  of  them.  A  hydronephrotic  cyst  does 
not  develop  forwards  from  the  epigastrium,  and  when  the 
colon  is  blown  up  it  is  easily  palpable  in  the  loin,  this  bowel 
being  then  often  found  medianwards  of  the  swelling.     Cysts 


376  INDICATIONS    FOR    OPERATION    IN 

of  the^mesentery  and  retention  cysts  of  the  cavity  of  the 
omentum  are  often  indistinguishable  from  pancreatic  cysts 
extending  forwards. 

INDICATIONS   FOR   OPERATION. 

Seeing  that  pancreatic  cysts  left  to  themselves  become 
progressively  larger,  operation  is  advisable  as  soon  as  there 
is  a  reasonable  certainty  of  the  condition.  Operation  will 
be  hastened  by  the  presence  of  marked  symptoms,  particu- 
larly pain.  Sudden  collapse,  associated  with  disappearance 
of  the  cyst  and  signs  of  peritoneal  shock,  point  to  rupture, 
and  constitute  an  absolute  indication  for  immediate 
operation.  Operative  intervention  will  consist  in  either 
opening  the  cyst  after  suture  to  the  abdominal  wall  in 
either  one  or  two  stages,  or  in  extirpation  of  the  cyst. 
Puncture,  either  for  diagnostic  or  therapeutic  purposes, 
is  a  very  dangerous  proceeding ;  five  out  of  seven  cases  so 
treated  died. 

Contra-indications. — There  cannot  be  said  to  be  any 
contra-indications  except  the  presence  of  such  general 
weakness,  or  intercurrent  disease,  or  advanced  age,  as  to 
render  any  operation  inadvisable. 

Prognosis. — Risks  and  results  of  operation. — Of  141  cases 
treated  by  suture  and  drainage  seven  died  as  a  result  of  the 
operation,  one  from  a  late  infection  from  the  fistula. 
Peritonitis  resulting  from  escape  of  the  fluid  into  the  general 
cavity  is  especially  to  be  feared.  In  22  cases  of  extirpation 
there  was  a  mortality  of  four  ;  this  method  is  more  serious 
and  more  risky.  A  fistula  may  persist  for  a  long  time  after 
operation,  even  for  several  years  ;  a  troublesome  eczema 
often  develops  around  the  fistulous  opening  ;  in  one  case 
death  occurred  from  erosion  of  the  splenic  artery.  Necrosis 
of  the  cyst  wall,  often  seen  after  incision,  may  give  rise  to 
septic  infection. 

Complete  recovery  is  frequent  after  both  drainage  and 
extirpation.  Ten  cases  reported  by  v.  Mikulicz  recovered 
entirely ;  in  two  the  cyst  was  extirpated ;  in  eight  it  was 
incised.  In  most  cases  recovery  is  permanent  ;  in  a  few 
cases  of  incision  recurrence  has  occurred.  As  a  rule  the 
symptoms  disappear  after  operation. 

Without  operation. — In  many  cases  death  has  occurred 
from  rupture  of  the  cyst  or  severe  haemorrhage  into   it. 


DISEASES    OF    THE    PANCREAS.  Z77 

The  tendency  is  for  the  cyst  to  grow  steadily,  and  produce 
all  the  painful  and  serious  symptoms  associated  with  large 
growths  of  the  upper  abdomen. 

LITERATURE. 

KoRTE.  Die  chirurgische  Krankheiten  des  Pankreas.  Deut. 
Chirurgie.     Stuttgart.      1898. 

KoRTE.  Pankreaskrankheiten.  Handbuch  d.  prakt.  Chir.  v. 
Mikulicz,  Bruns,  u.   Bergmann.     Bd.  iii.      1903. 

OsER.  Krankheiten  des  Pankreas.  Nothnagel's  Handbuch  d. 
spez.    Pathol,  u.  Therap.  Wien.      1898. 

Takayasu.  Beitr.  z.  Chir.  d.  Pankreas.  Mitteil.  a.  d.  Grenzge- 
biete  d.  Med.  u.  Chir.     Bd.  iii. 

MUNZER.  Pancreascysten.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Chir.      1903. 

V.  Mikulicz.  Ueber  den  Heutigen  Stand  der  Chirurgie  des 
Pankreas.  Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.  Bd.  xii, 
H.  I. 

Barker.  A  Case  of  Pancreatic  Cyst.  Brit.  Med.  Jour.,  March 
18,  1899. 

Pollard.  Three  Cases  of  Cyst  of  the  Pancreas.  Brit.  Med. 
Jour.,    March  n,   1899. 

DelagexNIere.  Des  Kystes  Glandulaires  du  Pancreas-  Arch. 
Provin.  de  Lyon.,  No.  4,  1900. 

M.  Heger.  La  Chirurgie  du  Pancreas.  Jour.  Med.  de  Bruxelles. 
5  annee,  No.  33. 

Tulasne.  Contribution  a  I'Etude  des  Kystes  Glandulaires  du 
Pancreas.     These  de  Paris.      1899. 


SOLID    TUMOURS    OF    THE    PANCREAS. 

Etiology. — The  etiology  of  tumours  of  the  pancreas 
is  that  of  new  growths  in  general.  Most  patients  affected 
are  about  middle  age.  Primary  cancer  is  more  frequently 
met  with  in  men  than  in  women. 

Pathological  Anatomy. — The  most  common  of  the 
primary  tumours  is  carcinoma  (scirrhus,  medullary, 
cylindrical-celled  carcinoma)  ;  much  less  common  are 
adenoma,  sarcoma,  tubercle,  and  gumma.  Primary  cancer 
is  met  with  most  commonly  in  the  head  of  the  pancreas  ; 
the  duct  is  sometimes  obliterated,  and  marked  compression 
of  the  common  bile-duct  is  also  frequent.  Perforation 
into  the  stomach  is  not  very  unusual. 

Clinical  Signs. — Intense,  sometimes  intermittent,  pain 
in  the  epigastrium  is  often  present.  In  more  than  three- 
fourths  of  all   cases   the  infiltrated  head  of  the    pancreas 


378  INDICATIONS     FOR     OPERATION     IN 

compresses  the  common  bile-duct  and  causes  jaundice  and 
clay-coloured  stools.  It  is  not  often  that  a  palpable 
epigastric  tumour  is  found  ;  if  present  it  much  assists  the 
diagnosis.  Such  a  tumour  will  usually  have  the  pulsations 
of  the  aorta  transmitted  to  it.  Glycosuria  and  fatty  stools 
have  only  rarely  been  recorded.  Sometimes  the  pylorus 
is  compressed  and  dilatation  of  the  stomach  caused. 

Cachexia  often  occurs  early,  and  once  established  it 
steadily  progresses  ;  intense  general  weakness  is  also  often 
an  early  symptom. 

Diagnosis. — In  a  case  of  jaundice  associated  with 
distension  of  the  gall-bladder,  where  symptoms  of  calculus 
are  absent  and  a  tumour  is  to  be  felt  in  the  epigastrium 
which  does  not  follow  the  movements  of  the  stomach,  a 
pancreatic  new  growth  should  be  suspected  (Korte).  In 
obliteration  of  the  bile-duct  by  calculus  the  gall-bladder 
is  usually  small  and  shrunken.  Stomach  tumours  are 
associated  with  chemical  changes  in  the  gastric  secretions, 
and  gastric  stagnation.  Tumours  of  the  colon  may  be 
differentiated  from  tumours  of  the  tail  of  the  pancreas  by 
inflating  the  stomach  and  colon  ;  a  tumour  of  the  tail  of 
the  pancreas  will  present  between  the  stomach  and  transverse 
colon. 

INDICATIONS   FOR   OPERATION. 

Korte  has  formulated  the  following  indications  :  "If 
a  tumour  of  the  pancreas  is  discovered  which  is  giving  rise 
to  symptoms,  and  if  after  careful  and  prolonged  examina- 
tion there  appears  to  be  a  chance  of  removing  it  entirely, 
operation  should  be  undertaken."  Radical  operation  con- 
sists of  extirpation  through  an  abdominal  incision.  The 
palliative  operations  are  the  establishment  of  a  biliary 
fistula,  cholecystenterostomy,  and  gastro-enterostomy  (for 
duodenal  obstruction).  Such  measures  will  only  be  taken 
when  the  symptoms  are  intolerable  ;  when,  for  example, 
there  is  pronounced  intestinal  stenosis,  with  much  suffering, 
or  some  other  very  troublesome  symptom,  such  as  intense 
pruritus  from  jaundice,  and  a  distended  gall-bladder. 

Contra-indications. — Long-standing  intense  jaundice  is  a 
contra-indication  to  operation  on  account  of  the  tendency 
to  haemorrhage  and  to  the  onset  of  severe  shock.  In  the 
absence  of  jaundice  no  operation  will  be  done  when  the 


DISEASES    OF     THE    PANCREAS.  379 

general  condition  is  low,  when  metastases  are  present,  or 
when  the  new  growth  has  encroached  on  neighbouring 
organs. 

Prognosis. — Risks  and  results  of  operation. — It  is  only 
rarely  that  a  chance  occurs  of  ridding  a  patient  of  a 
carcinoma  of  the  pancreas,  on  account  of  the  difficulties  of 
early  diagnosis  ;  yet  several  successful  cases  have  been 
placed  on  record.  The  risks  of  the  operation  are  con- 
siderable ;  several  patients  have  succumbed  immediately 
after  the  operation,  one  case  from  gangrene  of  the  colon. 
Cholecystostomy  obviates  cholsemia  but  produces  all  the 
inconveniences  of  a  biliary  fistula  for  the  rest  of  the 
patient's  life  —  discharge,  eczema,  etc.  In  20  cases  life 
was  prolonged  not  more  than  three  months  after  the 
operation  in  any  one.  Cholecystenterostomy  may  be 
followed  by  cholangitis  ;  nevertheless,  in  one  case  the 
patient  survived  the  operation  19  months,  in  another  12 
months  ;  operative  death  occurred  in  2  cases  out  of  12. 
On  the  whole  the  palliative  operations  for  pancreatic  tumour 
do  not  give  much  satisfaction.  One  of  my  patients  suc- 
cumbed some  weeks  after  opening  the  gall-bladder  ;  he 
derived  no  real  benefit  from  the  operation. 

Without  operation. — In  most  cases  carcinoma  of  the 
pancreas  terminates  in  death  from  four  to  five  months 
after  the  appearance  of  symptoms.  Benign  pancreatic 
growths  may  attain  enormous  dimensions,  and  cause 
intolerable  suffering,  particularly  by  compression  of  the 
bile-duct. 

LITERATURE. 

KoRTE.  Krankheiten  des  Pankreas.  Deut.  Chirurgie.  Stuttgart. 
1898. 

OsER.  Krankheiten  des  Pankreas.  Nothnagel's  Handbuch  d. 
Pathol,  u.  Therap.     Wien.      1898. 

Takayasu.  Beitr.  z.  Chir.  des  Pankreas.  Mitteil.  a.  d.  Grenzge- 
biete  d.  Med.  u.  Chir.     Bd.  iii. 

Franke.  Ueber  die  Exstirpation  der  krebsigen  Bauchspeichel- 
driise.     Arch.  f.  kUn.  Chir.     Ixiv,  H.  2. 

M  Heger.  La  Chirurgie  du  Pancreas.  Jour.  Med.  de  Bruxelles. 
5  annee,  No.  2ii- 

Terrier.     Carcinom.  des  Pankreaskopfcs.     Rev.  de  Chir.      1896. 

Mayo  Robson  and  Moynihan.     Diseases  of  the  Pancreas.      1903. 


CHAPTER     XXII. 

Diseases    of  the    Kidney   and    Renal    Pelvis. 


38: 


Chapter  XXII. 

DISEASES    OF    THE    KIDNEY    AND    RENAL 

PELVIS. 

BRIGHT'S    DISEASE. 

Etiology. — Acute  Bright's  disease  may  follow  one  of 
the  infective  diseases  or  develop  during  the  course  of  the 
same,  or  may  be  due  to  one  of  the  intoxications,  or  may 
arise  from  an  unknown  cause.  Chronic  nephritis  often 
supervenes  on  the  acute  disease,  or  may  be  due  to  some 
chronic  infective  disease  (syphilis,  tuberculosis),  or  to  a 
chronic  intoxication  (alcohol,  lead).  Granular  contracted 
kidney  occurs  from  the  same  causes,  but  also  from  diseases 
of  nutrition  (gout)  and  from  arteriosclerosis. 

Pathological  Anatomy. — In  post-mortem  examinations 
both  kidneys  have  always  been  found  diseased,  but  surgical 
autopsies  appear  to  show  that  the  disease  is  more  often 
at  first  unilateral.  The  inflammatory  condition  is  not 
always  diffuse ;  sometimes  it  is  circumscribed.  The 
following  forms  have  been  distinguished  :  acute  parenchy- 
matous nephritis,  usually  associated  with  enlargement  of  the 
organ  ;  chronic  parenchymatous  nephritis  (the  large  white 
and  the  large  mottled  kidney),  with  secondary  atrophy  ; 
and  the  genuine  contracted  kidney,  with  indurated  patches, 
and  often  associated  with  marked  endarteritis  of  the  renal 
arteries. 

Clinical  Course. — Acute  nephritis  often  runs  an  apyrexic 
course.  Pain  in  the  loin  and  tenderness  on  pressure  are 
often  to  be  noted.  The  amount  of  urine  is  usually  dimi- 
nished, high  coloured,  of  high  specific  gravity,  and  contains 
much  albumin,  blood,  and  numerous  granular  casts  beset 
with  red  cells  and  epithelial  cells.  Marked  general  cedema 
is  usually,  but  not  always,  present.     Cardiac  hypertrophy 


384  INDICATIONS    FOR    OPERATION    IN 

does  not  occur  in  the  first  weeks,  but  later  is  not  uncommon. 
Uraemia  often  develops. 

In  chronic  parenchymatous  nephritis  the  amount  of 
urine  passed  is  usually  but  little  less  than  normal,  and 
of  about  normal  specific  gravity,  containing  albumin 
and  blood  in  considerable  quantity.  The  deposit  contains 
numerous  granular  casts,  blood  corpuscles,  and  renal 
epithelia.  Occasionally,  but  rarely,  pure  blood  is  dis- 
charged for  a  considerable  time.  Hypertrophy  of  the  left 
ventricle  is  the  rule,  and  albuminuric  retinitis  is  frequently 
present.  Uraemia  is  relatively  uncommon  in  this  form  of 
nephritis.  Exceptionally  there  occur  cases  of  nephritis 
without  albuminuria  or  casts,  and  characterized  by  the 
onset  of  attacks  of  colic  and  haemorrhages.  Such  cases 
are  of  special  surgical  interest,  and  the  condition  appears 
to  be  usually  unilateral. 

In  secondary  and  primary  contracted  kidney  the  arterial 
tension  is  high  and  the  hypertrophy  of  the  left  ventricle 
pronounced.  The  urine  is  abundant,  clear,  and  of  low 
specific  gravity  ;  contains  little  albumin  and  few  casts 
or  renal  elements.  Cerebral  haemorrhage  and  advanced 
anasarca  are  common. 

Spontaneous  recovery  often  takes  place  in  acute  nephritis  ; 
in  some  cases  death  occurs  from  uraemia  or  heart  failure,  in 
others  chronic  nephritis  supervenes.  Chronic  parenchy- 
matous nephritis  often  produces  intense  oedema,  and 
terminates  fatally  in  the  course  of  twelve  to  twenty-four 
months.  The  progress  of  the  disease  is  often  intermittent  ; 
in  such  cases  periods  of  improvement  are  followed  by  acute 
haemorrhagic  exacerbations.  When  the  .condition  passes 
into  that  of  contracted  kidney  the  duration  of  life  is 
prolonged. 

In  the  different  forms  of  contracted  kidney  the  patient's 
existence  is  threatened  by  cardiac  insufficiency  and  uraemia  ; 
uraemia  may  have  an  acute  or  a  subacute  onset.  The 
diagnosis  of  the  different  forms  of  nephritis  is  based  chiefly 
on  the  urine  examination. 

INDICATIONS   FOR   OPERATION. 

The  question  of  operative  interference  in  Bright's  disease 
has  been  discussed  for  some  years,  but  opinions  still  differ 
much  as  to  the  indications.     Most  writers  are  in  agreement 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     385 

on  the  following  point :  that  in  acute  nephritis,  where  there 
is  marked  oliguria  or  anuria,  when  the  general  condition  is 
good,  and  there  is  marked  pain  and  tenderness  on  pressure 
over  one  or  both  kidneys,  operation  should  be  recommended 
(Lennander).  The  same  holds  true  for  acute  and  for  acute 
exacerbating  nephritis.  The  operation  consists  in  exposing 
the  kidney  and  removing  the  fibrous  capsule  (nephrolysis)  ; 
many  surgeons  also  make  an  incision  into  the  kidney  to 
relieve  tension. 

A  second  indication,  not  generally  agreed  upon,  is  the 
onset  of  acute  unilateral  or  bilateral  pain  in  cases  of  nephritis 
which  have  become  chronic  ;  here,  too,  nephrolysis  is 
practised. 

A  third  indication  is  the  occurrence  of  attacks  of 
hsematuria  associated  with  colic  ;  in  such  cases  operation 
is  sometimes  necessary  to  save  life. 

When  acute  uraemia  supervenes,  and  anuria  appears 
suddenly  in  the  course  of  nephritis,  operation  should  be 
undertaken,  according  to  Israel,  in  the  first  forty-eight 
hours,  whether  lumbar  pain  is  present  or  not.  The  operation 
will  consist  of  incision  of  at  least  one  kidney  for  the  relief 
of  tension.  In  acute  uraemia,  when  operation  for  some 
reason  or  other  is  impossible,  venesection  is  urgently  called 
for,  and  must  be  repeated  if  necessary,  and  followed  by  the 
injection  of  large  quantities  (^  litre)  of  normal  saline  (Leube). 
When  universal  oedema  is  present  and  cardiac  and  diuretic 
remedies  are  ineffectual,  the  lower  extremities  should  be 
scarified,  or  capillary  trochars  inserted  to  relieve  the  heart 
and  overcome  the  local  tension. 

Contra-indications. — Direct  operation  on  the  kidney  is 
contra-indicated  by  the  presence  of  severe  complicating 
disease,  especially  heart  failure,  atheroma,  and  organic 
heart  disease,  unless  the  renal  condition  immediately 
threatens  death,  as,  for  instance,  when  anuria  supervenes. 
If  the  diminution  in  urine  secretion  is  only  slight,  operation 
is  not  called  for,  since  spontaneous  improvement  often 
occurs.  Operation  is  not  justifiable  for  haematuria  of 
moderate  amount  and  short  duration. 

Chronic  urcemia  with  remissions  and  exacerbations 
contra-indicates  repeated  venesection. 

Extensive  eczema  of  the  legs  or  inflammatory  affections 
of   the   skin    contra-indicate   scarification  ;    if  done  under 

25 


386  INDICATIONS    FOR    OPERATION    IN 

such  conditions   there   is   a   risk   of  the   eczema  becoming" 
acute  and  spreading. 

Prognosis. — Risks  of  operation. — The  patient  must  as  a 
rule  be  anaesthetized  for  an  operation  on  the  kidney  ;  the 
risk  from  the  anaesthetic  is  relatively  considerable  on 
account  of  the  changes  in  the  heart  muscle  frequently 
present  ;  the  danger  of  heart  failure  is  particularly  great 
when  uraemia  with  complete  anuria  has  been  present  for 
several  days.  Even  when  done  earlier  the  risk  is  not  small, 
for  the  anaesthetic  preparations,  and  particularly  chloroform, 
exercise  a  deleterious  effect  on  the  renal  parenchyma,  and 
may  intensify  the  inflammatory  process. 

It  is  not  improbable  that  incisions  into  the  kidney  tissue 
are  followed  by  secondary  cicatricial  contraction.  In 
one  case  it  was  necessary  to  proceed  to  nephrectomy  eight 
days  after  the  operation  on  account  of  secondary  haemor- 
rhage ;  in  one  instance  gangrene  followed  operation.  A 
urinary  fistula  may  be  left  behind  by  the  operation. 

Puncture  and  scarification  may  be  followed  by  erysipelas 
or  phlegmonous  inflammation,  processes  which  are  specially 
prone  to  affect  patients  with  Bright's  disease  ;  repeated 
scarification  may,  however,  be  done  without  these  affec- 
tions supervening  ;  in  one  of  my  own  cases  this  was  done 
more  than  a  dozen  times  in  six  months  without  any  such 
complication. 

Results  of  operation. — In  many  cases  of  oliguria  or  anuria 
nephrolysis  or  incision  of  one  kidney  alone,  although  both 
were  affected,  has  been  followed  by  re-establishment  of 
secretion  and  disappearance  of  the  symptoms  threatening 
the  patient's  life.  Not  only  oliguria  but  also  serious  renal 
haemorrhage  has  been  sometimes  permanently  checked  by 
intervention.  In  uraemia  marked  improvement  is  often 
produced  by  venesection  and  injection  of  saline  solution  ; 
not  infrequently  the  alarming  symptoms  disappear. 

Scarification  often  remarkably  improves  the  condition 
of  the  cedematous  extremities,  and,  more  important  still, 
relieves  the  heart.  In  one  of  my  own  cases  29  litres  of 
fluid  came  from  the  legs  in  two  days.  In  many  cases  one 
has  seen  improvement  in  diuresis  and  diminution  of  oedema 
follow  this  small  operation. 

One  case  under  my  care  was  that  of  a  young  man  who, 
following  gonorrhoea,  had  high  fever,   and  complained  of 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     387 

intense  pain  in  the  left  loin.  There  were  traces  of  albumin 
in  the  urine,  pus  corpuscles  in  the  sediment,  no  casts. 
The  kidney  was  markedly  enlarged  and  tender  to  pressure. 
The  fever  persisted  several  weeks,  suppuration  was  suspected, 
and  the  kidney  was  cut  down  upon  ;  it  was  found  only 
to  be  enlarged  and  dark  red  in  colour,  and  on  section  the 
details  of  structure  were  obscured.  After  the  operation 
the  fever  disappeared  entirely  and  suddenly,  the  pains 
diminished,  the  albumin  soon  disappeared  from  the  urine, 
and  the  patient  made  a  rapid  recovery. 

Abstention  from  operation  means  in  many  cases  that 
the  patient  is  given  up  as  hopeless,  but  in  others  is 
dictated  by  the  prospect  of  relieving  or  possibly  curing 
the  patient  without  it. 

LITERATURE. 

.P.  K.  Pel.  Nierenentzundung  (M.  Brightii)  vor  dem  Forum  der 
Chirurgen.     Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  viii. 

J.  Israel.  Ueber  der  Einfiuss  der  Nierenspaltung  auf  akute  u. 
chronische  Krankheitsprozesse  des  Nierenparenchyms.  Mitteil.  a. 
d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  v. 

Idem.     Chir.    Khnik   der  Nierenkrankheiten.     Berhn.      1901. 

Naunyn.  Hamaturie  aus  Normalen  Nieren  und  bei  Nephritis. 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  v. 

Senator.     Die    Erkrankungen    der    Niere.     2nd    Ed.      1903. 

Strubell.  Der  Aderlass.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Chir.      1902. 

KoRTEWEG.  Die  Indikationen  zur  Entspannungsincision  bei 
Nierenleiden.     Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  viii. 

KuMMEL.  Die  Grenzen  erfolgreicher  Nierenexstirpation.  Arch. 
f.  klin.  Chir.     Bd.  Ixvii.      1902. 

Lennander.  Wann  kann  akute  Nephritis  Veranlassung  zu 
chirurgischen  Eingriffen  werden  ?  Mitteil.  a.  d.  Grenzgebiete  d. 
Med.  u.  Chir.     Bd.  x. 

Lepine.  Sur  rOpportunite  d'une  Intervention  Chirurgicale 
dans  la  Nephrite  Chronique.  La  Semaine  Medicale.  No.  49,  p.  397, 
1902. 

A.  PoussoN.  Traitement  Chirurgical  des  Nephrites  Medicales. 
Paris.     1904. 

RENAL   NEURALGIA 

{Nephralgia  Hcematurica,  Angioneurotic  HcBmaturia). 

Etiology. — There  is  no  single  etiological  cause  of  these 
affections.  The  attacks  are  caused  sometimes  by  changes 
in  the  kidneys  themselves,  sometimes  by  changes  in  their 


388  INDICATIONS    FOR    OPERATION    IN 

surroundings,  and  sometimes  are  due  to  nervous  affections 
(tabes). 

Pathological  Anatomy. — The  many  histological  in- 
vestigations which  have  been  carried  out  on  extirpated 
kidneys  or  portions  of  the  organ  have  shown  that  in  a 
considerable  number  more  or  less  extensive  nephritic 
processes  are  present.  This  inflammatory  condition  may 
be  unilateral  or  bilateral,  and  it.  is  sometimes  the  latter 
when  the  clinical  signs  are  all  referred  to  one  side.  Some- 
times there  is  displacement  or  adhesions  or  torsion  of  the 
kidney. 

Clinical  Course. — Renal  neuralgia  is  characterized  by 
very  intense  paroxysmal  pain,  often  associated  with  or 
followed  by  haematuria  ;  the  bleeding  may  consist  of  a 
single  large  haemorrhage.  The  pain  and  haemorrhage  are 
limited  to  one  side  ;  in  the  intervals  there  is  no  albumin 
in  the  urine.  In  rare  instances  casts — hyaline,  granular, 
or  epithelial — are  found,  without  albumin.  The  pain  often 
radiates  to  the  urinary  bladder  and  the  glans  penis.  The 
affection  may  persist  for  years  ;  between  the  attacks 
there  may  be  long  periods  of  quiescence,  extending  to 
several  years. 

Diagnosis. — The  attacks  resemble  those  which  are 
associated  with  calculus,  tuberculosis,  and  new  growths. 
If  there  are  no  signs  which  point  to  one  or  other  of  these 
morbid  affections,  such  as  calculi,  tumour  particles,  pus, 
tubercle  bacilli,  etc.,  the  diagnosis  of  renal  neuralgia  becomes 
probable  by  exclusion,  but  no  certainty  can  be  arrived  at 
as  to  the  actual  anatomical  change  present.  Rarely  in 
granular  contracted  kidneys  a  similar  train  of  symptoms 
occurs. 

INDICATIONS   FOR   OPERATION. 

If  a  probable  diagnosis  of  renal  neuralgia  is  arrived  at ; 
if  the  attacks  are  so  frequent  that  the  patient  is  insistent 
on  relief  ;  if  frequent  and  profuse  haemorrhages  are  sapping 
his  strength,  and  if  internal  treatment  fails,  an  exploratory 
operation  should  be  done  and  means  taken  to  deal  with 
whatever  abnormality  may  be  found,  for  example  by  the 
release  of  adhesions,  by  decapsulation,  or  fixation.  If 
haemorrhage  is  the  predominant  symptom,  incision  of  the 
kidney  is  indicated.     Operation  is  contra-indicated  by  the 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     389 

presence  of  serious  intercurrent  disease,  particularly  cardiac 
disease. 

Prognosis. — Results  and  risks  of  operation. — In  many 
cases  operation  has  had  a  favourable  influence  on  the 
condition,  and  not  infrequently  brings  about  complete 
relief.  In  some  cases  the  attacks  have  recurred  after 
a  variable  period  :  in  six  out  of  eleven  of  Israel's  cases 
this  happened.  The  risks  of  operation  appear  to  be 
considerable  ;  there  is  the  risk  of  diffuse  bilateral  renal 
inflammation,  increased  by  narcosis,  and  tending  to 
produce  a  condition  of  uraemia,  and  there  are  the 
risks  associated  with  degenerate  heart  muscle.  Of  the 
cases  operated  on  by  Israel,  three  died  as  a  result  of  the 
operation.  If  no  operation  be  undertaken,  a  very  grave 
state  of  affairs  may  supervene  from  anaemia  of  high  grade 
and  continued  attacks  of  pain. 

LITERATURE. 

Senator.  Die  Erkrankungen  der  Niere.  2nd.  Ed.  Wien. 
1903.       Nothnagel's  Handbuch  d.  spez.  Pathol,  u.  Therap.    Bd.  xix. 

Israel.  Chirurgische  Klinik  der  Nierenkrankheiten.  Berlin. 
1901. 

ZiEGLER.  Hsematuria  renalis.  Centralb.  f.  d.  Grenzgebiete  d. 
Med.  u.  Chir.,  No.   11,   1900. 

RovsiNG.  Operation  chronisch.  Nephritiden.  Mitteil.  a.  d. 
Grenzgebiete  d.  Med.  u.  Chir.     Bd.  x. 

Klemperer.  Behandlung  von  Nierenblutungen.  Therapie  der 
Gegenwart.      January,   1901. 

PoussoN.  Bull,  et  Mem.  de  la  Societe  der  Chir.  de  Paris.  No. 
20,  p.  590.      1898. 


RENAL    CALCULUS. 

Etiology. — Hereditary  tendencies  play  an  important 
part.  Gouty  families  are  often  affected.  The  condition 
is  common  above  the  average  in  certain  localities  ;  it  is 
most  frequent  in  chfldren  up  to  the  age  of  five  years,  and 
in  men  from  the  age  of  forty  upwards.  Foreign  bodies 
(distomum  and  fragments  of  tissue  debris),  and  traumatic 
haemorrhages  may  act  as  causative  factors.  The  catarrh 
of  the  urinary  passages  associated  with  affections  of  the 
spinal  cord  predisposes  to  calculus.  Renal  and  biliary 
calculi  have   often   been   found   present  simultaneously  in 


390  INDICATIONS    FOR    OPERATION    IN 

the  same  patient.  The  Distomum  hcBmatohium  is  an 
important  etiological  factor  in  tropical  countries. 

Pathological  Anatomy. — The  number  of  calculi  in 
a  kidney  varies  from  one  to  several  hundred.  The  oxalate 
stones  are  usually  single ;  the  multiple  stones  are  usually 
composed  of  urate  and  phosphate.  In  more  than  half  the 
cases  one  kidney  alone  is  affected,  particularly  the  left. 
Calculi  may  be  spherical  or  cylindrical  or  branched,  some- 
times ring-shaped;  they  may  reach  the  size  of  a  walnut. 
They  are  almost  always  in  the  pelvis,  calices,  or  ureter,  very 
rarely  in  the  parenchyma.  Most  common  are  the  yellow 
brown  uric  acid  stones,  next  the  dark  grey  mulberry  oxalate, 
then  the  greyish  white  phosphate  ;  rare  forms  are  composed 
of  calcium  phosphate  and  carbonate,  cystin,  xanthin. 
When  the  condition  is  bilateral  the  composition  of  the  two 
calculi  is  sometimes  different.  Associated  with  the  calculus 
there  is  sometimes  incrustation  of  the  renal  pelvis  with 
calcium  phosphate. 

The  renal  changes  may  be  aseptic  or  infected.  The 
aseptic  changes  consist  of  chronic  interstitial  inflammatory 
processes  of  the  renal  tissue,  processes  due  to  retention 
of  the  urinary  secretion,  and  hyperplasia  of  the  two  capsules. 
Israel  speaks  of  the  large  hard  calculous  kidney,  the 
shrunken  calculous  kidney,  the  hydronephrotic  calculous 
kidney  with  and  without  hypertrophy,  and  of  the  lipomatous 
calculous  kidney.  The  fatty  capsule  is  often  thickened 
and  adherent  to  the  capsula  propria,  and  this  fibroid 
change  may  extend  to  the  connective  tissue  of  the  kidney 
itself. 

A  calculous  kidney  may  be  infected  either  by  way  of 
the  blood  stream  or  from  the  bladder,  more  often  the 
former ;  a  peri-  and  paranephritis  follows,  either  of  acute 
purulent  or  chronic  type  ;  the  condition  of  the  kidney 
itself  is  one  of  pyelitis  or  pyonephrosis.  If  a  calculus  block 
the  ureteral  channel,  hydronephrosis  develops,  or  pyone- 
phrosis if  the  urine  is  infected,  with  general  atrophy  of  the 
renal  tissue. 

The  opposite  kidney  is  sometimes  hypertrophied.  General 
pysemia  does  not  often  occur  from  calculous  pyelitis.  When 
the  condition  is  of  long  standing  the  other  kidney  is  almost 
always  altered  (inflammation,  suppuration,  sclerosis, 
atrophy,  etc.).     Of  76  cases  collected  by  Legueu,  in  36  the 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     391 

other  kidney  contained  no  calculus,  but  in  31  there  was 
some  other  affection  of  the  opposite  organ. 

Ureteral  stones  sometimes  form  a  complete  cast  of  the 
ureter.  They  are  usually  single  and  most  frequently  in 
the  lower  part  of  the  channel,  where  they  may  be  palpated 
from  the  vagina  or  rectum. 

Clinical  Signs. — A  renal  calculus  may  be  present  for 
a  long  time  without  giving  rise  to  symptoms.  Usually 
they  are  attended  by  a  dull  pain  in  the  loin  increased  by 
pressure  on  the  abdomen,  by  movement  (walking,  jumping, 
riding,  etc.),  and  by  lumbar  compression.  The  pain  often 
radiates  along  the  course  of  the  ureter,  and  is  frequently 
referred  to  the  glans  penis  and  is  associated  with  violent 
tenesmus.  I  have  several  times  noted  anaesthesia  or 
hyperaesthesia  of  the  skin  along  the  course  of  the  ileo- 
hypogastric  nerve. 

Between  the  attacks  of  colic  the  urine  may  be  entirely 
clear  ;  violent  exercise  may  cause  a  blood  tinge  to  appear, 
or  the  amount  may  be  only  microscopic,  and  be  found 
in  the  sediment  as  washed-out  red  cells.  Profuse  h^ematuria 
without  colic  is  more  frequent  in  the  early  than  in  the  later 
stages.  In  the  intervals  a  brick-red  sediment  or  a  sediment 
of  phosphates  is  not  uncommonly  found.  If  the  calculi 
are  large  and  numerous,  they  may  sometimes  be  felt  on 
palpation,  provided  the  abdominal  wall  is  thin.  Radio- 
graphy gives  a  shadow  which  varies  in  density  according  to 
the  composition  of  the  calculus. 

The  attacks  of  colic  are  of  excessive  severit}^,  and  may 
come  on  without  warning,  or  be  preceded  by  slight  prodromal 
symptoms.  The  pain  is  usually  lumbar,  but  may  be  ill- 
defined  ;  it  radiates  most  frequently  to  the  testicle,  less 
commonly  to  the  thorax  and  shoulder.  There  is  frequent 
and  painful  desire  to  make  water,  and  at  the  commencement 
of  an  attack  rectal  tenesmus  and  vomiting ;  meteorism  is 
also  common.  Later,  but  occasionally  at  the  beginning, 
there  is  insuperable  constipation,  with  constant  fruitless 
tenesmus. 

The  amount  of  urine  is  small,  and  after  a  time  complete 
anuria  may  come  on  :  either  a  true  reflex  anuria,  or  bilateral 
blocking  of  both  ureters,  as  in  a  case  of  my  own  which  was 
examined  post  mortem.  Reflex  anuria  may  last  for  several 
days,  and  cause   death   by   unemic   poisoning.     In  one  of 


392  INDICATIONS    FOR    OPERATION    IN 

my  patients,  after  five  days'  anuria,  the  urinary  secretion 
returned  copiously,  the  other  kidney  showing  no  permanent 
lesion.  In  other  cases  the  amount  of  urine  is  only  lessened  ; 
it  is  turbid,  and  contains  blood  and  muco-pus ;  but  if  one 
kidney  is  blocked,  the  urine  passed,  coming  from  the  other 
side,  may  be  clear  and  abundant. 

The  duration  of  an  attack  may  be  from  an  hour  to  several 
days,  and  it  may  or  may  not  be  accompanied  by  fever.  If 
the  calculus  passes  into  the  bladder,  or  backwards  into 
the  renal  pelvis,  the  pain  ceases  abrupth^  After  an  attack 
small  concretions  or  gravel  are  often  discharged  ;  blood 
corpuscles  are  almost  always  found  in  the  urinary  sediment; 
traces  of  albumin  are  also  present,  and  occasionally  hyaline 
casts. 

Long-established  calculous  disease  is  almost  always 
associated  with  inflammatory  changes  in  the  renal  pelvis, 
and  pus  in  the  urine  to  a  greater  or  less  extent.  Such 
a  pyelitis  may  eventuate  in  perforation  of  the  pelvis  and 
the  formation  of  a  perinephritic  abscess.  In  other  cases 
the  kidney  becomes  pyonephrotic. 

During  the  attacks  the  kidney  is  swollen,  but  not  usually 
to  such  an  extent  as  to  be  noticeable  on  palpation.  When 
the  attacks  are  frequent,  and  a  hydronephrotic  or  pyone- 
phrotic condition  is  established,  the  enlargement  is  marked 
and  permanent.  Israel  found  that  in  30  cases  of  renal  and 
ureteral  stone  not  associated  with  hydro-  or  pyonephrosis, 
in  17  the  kidney  could  be  felt  enlarged  on  palpation. 

Diagnosis. — When  a  calculus  is  evacuated  after  an 
attack  of  colic  the  diagnosis  is  simple  and  clear.  In  other 
cases  it  is  difficult  and  is  founded  on  a  careful  consideration 
of  the  history,  on  the  presence  of  marked  tenderness  on 
bimanual  examination,  on  the  constant  occurrence  of  slight 
or  considerable  haemorrhage  after  exertion,  on  the  presence 
in  the  urine  of  albumin,  pus  cells,  crystals,  and  sometimes 
casts,  on  the  radiation  of  the  pain  to  the  penis  or  testicle, 
on  sensory  disturbances  in  the  course  of  the  ileohypogastric 
nerve,  and  on  the  positive  results  of  radiographic  examina- 
tion. The  oxalate  and  uric  acid  stones  give  a  dense  shadow  ; 
the  phosphatic  are  much  less  satisfactory  in  this  respect. 

I  think  it  necessary  to  utter  a  warning  against  basing 
the  diagnosis  only  on  a  radiographic  picture  ;  in  a  case 
which  I  saw  in  consultation  with  others  of  pain  in  the  loin 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     393 

and  occasional  microscopic  traces  of  blood  in  the  urine, 
a  radiograph  showed  what  was  apparently  a  distinct  group 
of  facetted  calculi,  but  operation  showed  no  calculus  in 
either  pelvis  or  ureter  ;  possibly  the  sharply-defined  shadows 
were  due  to  uric  acid  infarcts  in  the  renal  pyramids. 

In  other  cases  radiography  is  of  much  assistance  in 
support  of  the  diagnosis  when  the  symptoms  are  not  typical. 

Ureteral  catheterization  for  purely  diagnostic  purposes 
is  too  risky  a  proceeding  for  routine  use. 

Differential  diagnosis  is  sometimes  very  difficult.  Chronic 
appendicitis  may  simulate  nephrolithiasis,  but  the  charac- 
teristic radiation  of  the  pain  is  absent,  and  there  are  no 
changes  in  the  urine,  although  there  may  be  dysuria. 

In  attacks  of  biliary  colic  without  jaundice  the  gall-bladder 
is  enlarged  and  tender,  and  the  physical  diagnosis  is  made 
easier  if  the  patient  is  turned  over  on  to  the  left  side.  In 
intestinal  colic  there  is  no  tenderness  on  pressure  in  the 
painful  area.  Local  examination  will  usually  exclude 
disease  of  the  genital  organs.  In  ulcer  of  the  stomach 
or  duodenum  the  situation  of  the  pain  is  away  from  the 
kidney,  and  there  are  no  urinary  changes.  Colic  due  to 
sudden  distension  of  the  renal  capsule  may  be  confused 
with  nephrolithiasis.  In  occlusion  of  the  ureter  causing 
hydronephrosis  the  organ  is  much  enlarged,  and  when 
the  obstruction  is  relieved  hsematuria  often  occurs,  the 
kidney  returning  to  its  normal  size.  In  renal  tuberculosis 
pus  and  albumin  are  usually  persistently  present  in  the 
urine ;  sometimes  the  bacilli  may  be  demonstrated  and 
fever  is  frequent,  while  characteristic  changes  at  the  ureteral 
orifices  may  often  be  demonstrated  by  the  cystoscope. 
Torsion  or  dislocation  of  a  floating  kidney  may  usuallv 
be  distinguished  by  a  careful  physical  examination  and 
attention  to  the  history. 

In  pyonephrosis  the  urine  is  often  clear  during  an  attack 
of  colic  and  full  of  pus  after  it  has  passed.  Renal  tumours 
are  usually  not  tender  to  pressure  ;  the  haemorrhages  to 
which  they  give  rise  usually  occur  suddenly,  without 
reference  to  exertion  or  movement,  and  clots  are  often 
passed. 

Hysterical  nephralgia  can  sometimes  only  be  distinguished 
from  stone  by  the  constant  absence  of  blood  cells  and 
albumin  from  tlie  urine. 


394  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS    FOR   OPERATION. 

Under  some  circumstances  renal  calculus  threatens  life, 
and  operation  is  then  absolutely  indicated.  This  is  the 
case  in  the  presence  of  calculous  anuria,  a  condition  which 
may  be  due  to  bilateral  occlusion  of  the  ureter,  or  to  occlusion 
of  one  and  reflex  inhibition  of  the  opposite  kidney,  or  to 
the  occlusion  of  one  ureter  when  there  is  but  one  kidney. 
Spontaneous  disappearance  of  reflex  anuria,  after  treatment 
with  drugs,  hot  baths,  etc.,  is  improbable  when  the  pains 
of  colic  have  ceased,  and  when  after  the  cessation  of  colic 
the  patient  still  does  not  pass  urine. 

Disorganization  of  the  renal  parenchyma,  leading  to 
fatal  uraemia,  frequently  sets  in  by  the  third  day,  although 
it  may  be  delayed  to  the  sixth  or  even  the  tenth,  so  that 
the  possibility  of  spontaneous  disappearance  in  calculous 
anuria  must  not  be  relied  upon  for  longer  than  twenty-four 
hours  after  onset. 

On  which  side  is  the  operation  to  be  done  ? 

When  there  is  unilateral  nephrolithiasis  the  affected 
kidney  is  to  be  dealt  with  ;  when  bilateral  the  kidney  which 
appears  from  clinical  signs  to  have  been  last  occluded, 
because  the  onset  of  complete  anuria  will  have  been  due 
to  this.  If  the  clinical  symptoms  and  the  radioscopic 
examination  do  not  afford  any  definite  information  (for 
example,  when  coma  supervenes  without  antecedent  colic), 
that  kidnej'  should  be  operated  on  which,  judging  from 
the  history,  it  seems  probable  has  suffered  least  destruction. 
If  no  calculus  is  found  on  the  one  side  the  other  kidney 
should  then  be  exposed  if  urjemic  symptoms  are  actually 
present,  but  if  the  uraemia  has  not  at  that  time  come  on 
the  second  operation  may  be  postponed  a  day  or  two, 
because  sometimes  incision  on  the  one  side  reflexly  relieves 
the  opposite  kidney.  If,  however,  at  this  operation  the 
kidney  is  found  much  altered  although  there  is  no  calculus, 
the  other  kidney  should  be  at  once  incised  even  though 
there  is  no  present  ursemia. 

The  difficulties  that  may  arise  are  illustrated  by  the 
following  case.  In  a  man,  aged  40,  after  shooting  pains 
along  the  course  of  tlie  ureters  and  slight  transient  hsema- 
turia,  anuria  suddenly  came  on,  with  intense  vesical 
tenesmus.     The  left  kidney  was  found  enlarged  and  tender. 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     395 

Operation  was  done  on  the  third  day  ;  a  large  calculus  was 
removed  from  the  left  side,  and  this  kidney  at  once  resumed 
function.  The  next  day  anuria  came  on  again,  and  soon 
passed  into  fatal  uraemia  before  a  second  operation  could 
be  done.  At  the  autopsy  a  calculus  was  found  blocking 
the  right  ureter  ;  there  were  no  symptoms  during  life 
pointing  to  the  right  side. 

A  second  absolute  indication  for  operation  is  the  onset 
of  symptoms  pointing  to  acute  pyelonephritis  of  one  kidney. 
Such  symptoms  are  : — Fever,  sometimes  pyjemic  in  charac- 
ter, with  frequent  rigors  and  profuse  sweating,  dry  tongue, 
vomiting,  marked  pain  and  tenderness  on  pressure  in  the 
region  of  the  kidney,  pus,  and  occasionally  hyaline  and 
granular  casts  in  the  urine.  Even  if  fever  is  absent  and 
the  general  condition  is  not  seriously  affected,  operation 
is  indicated  when  the  urine  contains  pus  and  the  cystoscope 
shows  that  this  is  coming  from  one  side. 

A  third  absolute  indication  is  the  onset  of  hcemonhage 
in  renal  calculus  in  such  quantity  as  to  threaten  life  ;  this, 
however,  rarely  happens.  A  fourth  absolute  indication 
is  met  when  a  calculus  is  impacted  in  the  ureter,  and  has 
remained  there  for  some  considerable  time ;  such  cases 
always  terminate  either  in  retention  or  infection  if  left  alone. 

Operation  is  further  indicated,  although  not  as  an  indicatio 
vitalis,  in  the  following  conditions  : — 

(a)  When  hydronephrosis  and  calculus  co-exist,  because 
the  first  is  often  provoked  by  the  second.  If  such  a  calculous 
hydronephrosis  becomes  infected  and  pyonephrosis  super- 
venes, removal  of  the  kidney  is  urgently  called  for. 

(b)  Even  when  the  symptoms  are  slight,  pus  in  the  urine 
is  a  sign  which  indicates  operation,  whether  the  kidney  is 
enlarged  or  not. 

(c)  When  the  patient  has  to  work  for  his  living,  and  is 
prevented  from  doing  so  by  continuous  dull  pains  or  repeated 
colic,  with  or  without  the  passage  of  calculi.  This  indication 
holds  whether  the  calculous  kidney  is  infected  or  not. 

{d)  In  patients  better  situated,  when  there  is  much  com- 
plaint of  pain  and  distress  and  consequent  mental  depression. 

[e)  When  a  patient  lives  or  travels  out  of  the  reach  of 
surgical  assistance  ;  in  particular  when  he  has  already  had 
pronounced  attacks  of  colic,  and  radioscopy  shows  a  stone 
present. 


396  INDICATIONS    FOR    OPERATION    IN 

Almost  all  authors  are  agreed  that  the  conditions  which 
I  have  enumerated  should  be  accepted  as  indications  for 
operation.  Others,  for  example  Rovsing,  Tuffier,  and 
Henry  ]\Iorris,  go  further ;  they  consider  operation  called 
for  in  all  cases  where  a  definite  diagnosis  of  renal  stone  can 
be  made,  whether  the  condition  is  aseptic  or  infected, 
simple  or  complicated.  Other  surgeons  operate  even 
when  the  question  of  the  presence  of  stone  only  amounts 
to  a  reasonable  probability  ;  they  hold  that  the  dangers 
of  delay  are  greater  than  those  of  prompt  operation,  and 
that  to  wait  for  signs  of  infection  is  to  increase  the  risks 
of  operation. 

This  latter  opinion  probably  goes  too  far,  and  the  practi- 
tioner should  not  base  his  advice  as  to  operation  upon  it 
without  hesitation.  Operation  even  on  a  non-infected, 
uncomplicated,  and-  "  silent  "  kidney,  is  not  so  free  from 
risk  as  some  of  its  advocates  argue.  Rovsing  admits  a 
mortality  of  7  in  115  cases.  One  cannot,  therefore,  promise 
the  patient  that  such  operations  are  free  from  risk,  since, 
as  Israel  remarks,  the  prognosis  of  each  case  has  some 
uncertainty  about  it,  even  though  statistics  show  that 
no  other  major  operation  can  show  so  small  a  mortality 
(Morris).  It  is  a  fact  that  the  presence  of  a  renal  stone 
is  compatible  in  many  cases  with  long  life  and  good  health, 
even  when  there  are  occasional  slight  attacks  and  haemor- 
rhages. This  is  my  own  experience,  and  it  is  supported 
by  Rosenstein,  and  I  may  express  my  opinion  on  the  matter 
by  saj'ing  that,  in  my  view,  the  presence  of  a  renal  stone 
does  not  in  itself  constitute  an  indication  for  operation, 
but  that  some  one  of  the  complications  already  mentioned 
should  be  present  before  operation  is  recommended. 

The  operation  most  frequently  employed  is  nephrotomy, 
with  incision  through  the  renal  cortex,  less  frequently 
through  the  wall  of  the  pelvis.  Extirpation  (when  the 
kidney  is  completely  disorganized  by  suppuration)  and 
partial  extirpation  are  only  rarely  called  for.  According 
to  Kiister  total  extirpation  is  required  under  the  following 
conditions  : — 

(a)  Atrophy  of  the  parenchyma,  owing  to  the  presence 
of  numerous  large  calculi. 

(b)  In  sacciform  purulent  kidneys,  and  when  pyelo- 
nephritis has  largely  destroyed  the  organ. 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     397 

(c)  In  septic  paranephritis  around  a  kidney  more  or  less 
disorganized. 

(d)  In   persistent   fistula   after  nephrolithotomy. 

{e)  In  stenosis  of  the  ureter  after  nephrotomy,  which 
cannot  be  treated  by  other  means. 

Contra-indications. — According  to  what  has  been  already 
said,  when  the  attacks  are  infrequent  and  slight,  no  operation 
is  called  for.  Even  when  small  stones  are  passed  repeatedly 
with  or  without  colic,  operation  is  not  indicated  if  the 
patient  is  quite  well  in  the  intervals,  and  the  urine  is  clear 
and  contains  no  renal-formed  elements.  Operation  cannot 
influence  the  disposition  to  the  formation  of  fresh  calculi 
(Israel).  Bilateral  non-infected  nephrolithiasis  is  not  a 
contra-indication  to  operation,  but  it  is  otherwise  with 
double  infected  calculous  disease,  especially  if  the  general, 
condition  is  bad.  Advanced  age  is  also  a  contra- 
indication. 

Prognosis. — Risks  of  operation. — The  risks  vary  with  the 
nature  of  the  operation  and  the  state  of  the  kidney.  The 
operative  mortality  in  non-infected  calculous  disease  amounts 
only  to  a  small  percentage,  but  in  the  infected  form  it  is  very 
high  (as  much  as  a  fourth  of  all  cases),  whether  for  nephro- 
lithotomy or  nephrectomy.  Death  occurs  usually  from 
heart  failure  or  uraemia.  Operation  is  sometimes  followed 
by  urine  infiltration,  septic  paranephritis,  and  sometimes 
gangrenous  inflammation  of  the  soft  parts.  Occasionally 
serious  post-operative  haemorrhage  has  occurred. 

In  61  cases  of  nephrolithiasis  without  anuria  operated 
on  by  Israel,  the  operative  mortality  was  147  per  cent, 
and  one  later  accidental  death.  Of  12  with  calculus  in 
the  ureter  4  died,  of  5  with  calculous  anuria  two  died. 
The  operative  mortality  is  lowest  (i  in  29)  in  aseptic  or 
only  slightly-infected  cases,  highest  in  highly-infected  cases 
when  conservative  operations  are  done  (38  per  cent),  so 
that  in  the  latter  class  nephrectomy  is  indicated  as  the 
least  dangerous  procedure.  Kiister  collected  493  cases 
of  unspecified  types  treated  by  nephrotomy,  and  of  these 
90  (18  per  cent)  died  after  operation  ;  of  193  treated  by 
nephrectomy  44  died  (over  20  per  cent). 

After  operation,  and  particularly  after  pyelolithotomy, 
fistulae  sometimes  persist  for  a  long  time  ;  in  some  cases 
faecal  fistulae  have  been  recorded  from  operative  lesion  of 


398  INDICATIONS    FOR    OPERATION    IN 

the  intestine.  If  the  kidney  is  spht,  some  of  the  parenchyma 
must  atrophy,  though  the  amount  may  be  small  ;  different 
authors  have  held  the  opinion,  and  in  my  view  with  reason, 
that  such  loss  of  substance  is  not  insignificant  from  the 
point  of  view  of  the  renal  function. 

Results  of  operation. — Having  laid  stress  on  the  risks 
and  mortality  of  operation,  it  is  right  to  state  that  many 
cases  are  completely  and  permanently  cured  of  their 
disease.  It  appears  that  the  formation  of  fresh  calculi 
after  operation  may  be  avoided  by  suitable  dieting.  Israel 
states  that  in  his  experience  re-formation  is  rare  in  the 
case  of  uric  acid  and  oxalate  calculi. 

Without  operation. — If  operation  is  withheld  in  the 
presence  of  what  have  been  enumerated  above  as  absolute 
indications,  death  will  occur  from  heart  failure  or 
uraemia,  or  there  may  develop  a  state  of  general  infection 
from  the  infected  kidney.  In  a  kidney  whose  ureter  is 
blocked  by  a  stone,  desquamative  processes  usually  take 
place  which  may  damage  the  function  of  the  organ,  and 
this  damage  may  persist  after  the  stone  is  gone.  In  other 
cases,  when  there  is  marked  pyelitis,  the  condition  may 
spread  to  the  whole  of  the  urinary  passages  and  the  other 
kidney,  and  induce  amyloid  disease.  In  acute  pyelo- 
nephritis of  one  side,  severe  toxic  infection  may  be  induced 
on  the  other  side  and  seriously  endanger  life. 

Under  the  conditions  which  have  been  enumerated  as 
relative  indications,  the  patient,  if  no  operation  is  done, 
may  become  quite  incapable  of  work,  and  his  life  may  be 
a  burden  to  him  on  account  of  persistent  pain. 

When  hydronephrosis  develops  from  retention  in  a 
calculous  kidney,  the  parenchyma  will  atrophy  from 
pressure  unless  operation  is  done  to  relieve  the  block. 
If  the  hydronephrosis  becomes  infected,  and  operation  be 
withheld,  the  one  kidney  becomes  disorganized,  and  secon- 
dary infection  may  occur  in  the  other. 

LITERATURE. 

RosENSTEiN.  Krankheiten  der  Niere.  Handbuch  d.  prakt. 
Med.  V.  Ebstein-Schwalbe.     Bd.  iii. 

ScHEDE.  Nierenkrankheiten.  Handbuch  d.  prakt.  Chir.  Berg- 
mann,  Bruns,  u.  Mikulicz.      2nd  Ed.      1903. 

Wagner.  Nephrolithiasis.  Centralb.  f.  d.  Grenzgebiete  d.  Med. 
u.  Chir.      19CX). 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     399 

Senator.  Krankheiten  der  Niere.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Therap.     2nd  Ed.     1903. 

Israel.  Chir.  Klinik  der  Nierenkrankheiten.  Berlin.  1901. 
Operationen  bei  Nierensteinen.  Langenbeck's  Arch.  Bd.  Ixi. 
1900. 

RovsiNG.  Diagnose  und  Behandlung  der  Nierensteine.  Arch, 
f.  klin.  Chir.     h.      1895. 

Sendler.  Indikationen  chirurg.  Eingriffe  bei  Nierenkrankheiten. 
Miinch.   med.  Wochens.,   5   &  6,    1899. 

Morris.     Surgical  Diseases  of  the  Kidney  and  Ureter. 

KiJSTER.     Chirurgie   der   Nieren.     Deut.    Chir.      1902. 

PiEDVACHE.  De  la  Nephrolithotomie  comme  Traitement  d^ 
la  Lithiase  Renale.     These  de  Paris.      1896. 

Annales  des  Maladies  des  Organs  Genit.-urin.,  1895-1900 — Pousson 
(i898),Resnikoff-Grube  (1895),  Regnier  (1899),  Secchi  (i897),Tedenat 
( 1 898 ),  Vignard  (1898),  Tuffier  (1898). 


RENAL    CONTUSIONS. 

Etiology. — The  accident  which  usually  produces  this 
lesion  is  a  blow  in  the  lumbar  region.  Blows  inflicted 
more  laterally  or  anteriorly  may  also  cause  it,  or  forcible 
compression  between  two  resistances.  Occasionally  it 
is  due  to  sudden  forcible  contraction  of  the  abdominal 
muscles.     As  a  rule  one  kidney  only  is  affected. 

Pathological  Anatomy. — The  lesions  vary  in  extent. 
There  may  be  simply  a  splitting  of  the  capsule,  or  there  may 
be  a  tear  in  the  kidney  substance  without  involving  the 
pelvis,  or  the  tear  may  extend  through  into  the  pelvis. 
Sometimes  part  of  the  kidney  is  completely  separated, 
especially  in  lesions  near  the  poles.  The  haemorrhage 
is  always  considerable,  and  the  renal  pelvis  is  usually 
full  of  clots.  Secondary  abscesses  frequently  develop 
in  or  around  the  kidney. 

When  the  injury  is  very  severe  the  whole  kidney  may  be 
destroyed,  in  which  case  a  gangrenous  condition  supervenes 
if  the  patient  survives.  Occasionally  the  pelvis  is  torn 
away  from  the  kidney  proper,  or  the  ureter  and  other 
structures  of  the  hilum  may  be  torn  through  ;  if  the  artery 
and  vein  are  torn  the  whole  kidney  necroses. 

Symptoms. — The  general  symptoms  are  shock  or  profound 
collapse,  vomiting,  and  profuse  perspiration  ;  they  may 
appear  at  once,  or  come  on  some  hours  after. 

Locally,  there  is  blood  extravasation  into  the  loin,  and 


400  INDICATIONS    FOR    OPERATION    IN 

later,  days,  or  it  may  be  weeks  after,  into  the  skin  in  the 
region  of  the  inguinal  canal.  Usually  there  is  intense 
local  pain,  generally  much  increased  on  movement.  If 
clots  pass  down  the  ureter,  pain  radiates  to  the  testicle, 
the  hip,  or  the  groin,  and  the  testicle  is  retracted.  These 
pains  are  often  very  persistent,  and  may  last  for  weeks. 

There  is  usually  blood  in  the  urine,  and  when  there  are 
clots  great  pain  may  accompany  its  passage.  At  the  same 
time  symptoms  of  severe  internal  hfemorrhage  may  develop 
and  prove  fatal,  but  death  is  exceptional  from  this  cause 
within  the  first  twenty-four  hours  ;  when  it  occurs  it 
is  due  to  the  fall  in  blood  pressure  produced  by  the  state 
of  shock. 

When  the  acute  symptoms  have  passed,  a  condition  of 
traumatic  nephritis  may  be  left,  signalized  by  the  presence 
of  albumin  and  casts  in  the  urine. 

Immediately  after  the  accident  there  may  be  oliguria, 
and  in  some  cases  this  amounts  to  a  reflex  anuria  ;  occa- 
sionally polyuria  has  been  recorded.  Marked  meteorism 
is  present  in  many  cases. 

If  the  peritoneum  be  torn  and  urine  Irnd  its  way  into 
the  peritoneal  cavity  the  patient  may  die  from  septic 
peritonitis. 

Diagnosis. — Contusion  of  the  kidney  is  to  be  diagnosed 
when  a  lumbar  or  abdominal  injury  is  followed  by  swelling 
and  tenderness  on  pressure  in  the  loin,  haematuria  in  greater 
or  lesser  amount,  and  meteorism  of  the  large  bowel.  If 
the  pulse  and  temperature  rise  gradually,  and  if  the  abdo- 
minal pain  extends  and  increases,  extravasation  into  the 
peritoneal  cavity  is  indicated. 

INDICATIONS   FOR   OPERATION. 

If  after  an  injury  there  are  signs  of  serious  renal  hsemor- 
rhage,  operation  is  called  for.  Such  haemorrhage,  without 
being  copious  at  first,  may  be  continuous,  and  in  this  way 
become  serious  in  itself  after  some  days  or  even  weeks. 
•Operation  consists  in  nephrotomy  and  arrest  by  packing  ; 
if  the  organ  is  much  damaged  it  must  be  removed.  If 
the  signs  point  to  the  peritoneum  being  involved,  a  trans- 
peritoneal operation  will  be  advisable. 

Operation  may  also  be  called  for  on  account  of  the  onset 
■of    signs    of    inflammatory    reaction    around    the    kidney  ; 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     401 

such  signs  are  increase  in  the  local  pain  and  tenderness, 
fever,  and  perhaps  rigors.  When  operation  reveals  a 
collection  of  septic  urine  or  pus  around  the  kidney,  nephrec- 
tomy is  the  only  procedure  from  which  a  good  result  is 
to  be  expected. 

Contra-indications. — The  presence  of  pronounced  shock 
from  serious  lesions  to  other  organs  makes  it  necessary 
to  postpone  operation  for  the  renal  condition.  It  is  unneces- 
sary to  operate  simply  for  slight  haemorrhage  of  short 
duration,  because  minor  renal  contusions  often  heal 
spontaneously  ;  nor  should  operation  be  undertaken  simply 
on  account  of  the  presence  of  a  haematoma  in  the  loin, 
unless  this  becomes  progressively  larger,  is  associated 
with  ansemia,  or  shows  signs  of  infection. 

Prognosis.  —  Results  of  operation.  —  In  many  cases 
packing  of  the  wound  in  the  kidney  or  nephrectomy 
has  given  excellent  results.  Schede  has  collected  16 
cases  of  nephrectomy  for  serious  haemorrhage,  with  14 
recoveries. 

Without  operation. — Of  306  cases  collected  by  Maas 
and  Kiister,  in  222  the  condition  was  uncomplicated  by 
lesions  of  other  organs,  and  among  these  there  was  a 
mortality  of  30  per  cent.  A  half  of  all  the  cases  taken 
together  ended  fatally.  The  deaths  due  to  shock  all 
occurred  within  24  hours.  Haemorrhage  was  the  cause 
of  death  in  about  half  the  fatal  cases  ;  in  some  the  death 
took  place  late,  but  in  most  within  a  month.  Septic  infec- 
tion accounted  for  most  of  the  other  fatalities,  and  most 
frequently  within  the  first  four  weeks. 

These  figures  show  that  the  prognosis  of  renal  injuries  is 
always  very  serious,  on  account  of  the  risks  from  haemor- 
rhage or  infection.  Recovery  is  often  also  incomplete  ; 
long-persisting  fistuke  may  be  left,  and  hydronephrosis 
may  occur  from  dislocation  of  the  organ.  Interstitial 
nephritis  and  calculi  also  occur  as  sequelae. 

LITERATURE. 

KusTER.    Die  Chirurgie  der  Nieren.     Deut.  Chir.     P.  52b. 

Schede.  Chirurgische  Nierenkrankheiten.  Handbuch  d.  prakt. 
Chir.     Bruns,  Bergmann,  u.  Mikulicz.     2nd  Ed.     Stuttgart.     1903.' 

Edelfsen.  Niercnquetschung  oder  Nierenentzundung  ?  Munch, 
med.  Wochens.     Nos.  5  &  6,  1902. 

Albarrax.     Traite    de   Chirurgie.     Bd.    iii.     Paris.      1899. 

26 


402  INDICATIONS    FOR    OPERATION    IN 

MOVABLE    KIDNEY. 

Etiology. — Congenital  anomalies  are  the  most  important 
etiological  factors  in  this  condition.  Other,  and  for  the 
most  part,  contributory  causes,  are  relaxation  of  intra- 
abdominal support  (from  repeated  pregnancy,  rapid  wasting, 
the  removal  of  large  abdominal  tumours,  or  the  development 
of  large  ventral  hernise),  vertebral  scoliosis,  injury,  severe 
muscular  exertion.  The  condition  is  also  ascribed  to 
tight-lacing  and  the  wearing  of  high-heeled  shoes.  It  also 
occurs  from  increase  in  weight  of  the  kidney  itself,  and 
when  the  diaphragm  is  pushed  down  from  one  cause  or 
another. 

Pathological  Anatomy. — The  movable  kidney  may 
or  may  not  be  surrounded  by  its  fatty  capsule  ;  it  usually 
rotates  in  its  descent,  so  that  the  hilum  looks  upwards, 
but  this  may  not  occur  if  the  vessels  are  long,  extensile,  or 
implanted  low.  The  displaced  organ  may  be  fixed  by 
perinephritic  adhesions.  Hydronephrosis  is  relatively 
common,  torsion  of  the  pedicle  relatively  rare.  Many 
cases  have  been  recorded  complicated  by  inflammatory 
changes  in  the  appendix. 

Clinical  Signs.— i\Iost  patients  with  movable  kidney 
suffer  no  inconvenience,  and  it  is  often  discovered  by  chance. 
Sometimes  the  symptoms  are  extraordinarily  manifold, 
but  many  may  be  due  to  other  morbid  conditions  present : 
enteroptosis,  disease  of  the  genital  organs,  etc.  Israel 
places  the  symptoms  in  three  groups  : — 

1.  Pain  on  standing,  walking,  sitting,  which  disappears 
when  the  patient  lies  down. 

2.  Dyspeptic  symptoms  of  the   "  nervous  "   type. 

3.  Attacks  of  typical  renal  colic,  which  must  be  looked 
upon  as  due  in  part  to  kinking  of  the  ureter  and  in  part 
to  circulatory  disturbances  evoked  by  twisting  of  the 
vessels. 

The  attacks  of  pain  are  violent,  and  come  on  suddenly, 
associated  with  faintness,  collapse,  nausea,  cold  perspiration, 
and  a  small,  rapid  pulse.  The  kidney  is  felt  to  be  enlarged 
and  tender  to  pressure.  In  many  cases  the  attack  passes 
off  suddenly,  and  is  followed  by  polyuria.  When  attacks 
are  often  repeated  the  condition  takes  the  form  of  periodic, 
hydronephrosis. 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     403 

If  the  attacks  of  pain  caused  by  renal  mobility  do  not 
soon  disappear  when  the  patient  lies  down  and  the  kidney 
is  replaced,  or  if  they  occur  during  rest  in  bed,  there  is 
reason  to  suspect  that  the  condition  is  due  to  some  organic 
renal  disease,  or  to  disease  in  some  other  abdominal  organ, 
or  to  some  form  of  neuropathy.  According  to  Stiller 
there  is  often  some  abnormal  mobility  of  the  tenth  rib. 
The  condition  is  often  bilateral ;  when  unilateral  the  right 
is  more  frequently  affected  than  the  left. 

Diagnosis. — The  diagnosis  is  easy  when  the  kidney  is 
to  be  felt  out  of  its  normal  position  and  can  be  replaced. 
When  lying  in  its  bed  a  movable  kidney  descends  abnormally 
low  during  inspiration  and  can  be  easily  displaced  downwards 
with  the  hands.  If  the  tumour  corresponds  with  the  kidney 
in  size  and  shape,  and  is  smooth  on  the  surface,  and  if  the 
vessels  of  the  hilum  are  palpable,  the  diagnosis  is  clear. 
Confusion  with  other  structures  frequently  occurs  ;  a 
detached  lobe  of  the  liver  presents  a  sharp  edge  at  least  at 
one  of  its  borders,  and  if  the  patient  is  examined  lying 
on  the  left  side  the  right  kidney  will  be  felt  in  place.  An 
enlarged  gall-bladder  with  a  long  pedicle  may  be  displaced 
from  right  to  left  but  not  downwards,  nor  can  it  be  mani- 
pulated into  the  renal  region  ;  in  spite  of  this  such  cases 
may  present  great  diagnostic  difficulties.  Tumours  of 
the  ascending  colon  are  associated  with  colic  and  are  not 
always  easy  of  palpation,  but  can  usually  be  distinguished 
from  movable  kidney  by  careful  examination  ;  the  distended 
gut  will  be  seen  to  collapse  with  loud  intestinal  gurgling, 
and  the  tumour  itself  is  movable  in  a  transverse  but  not 
in  a  sagittal  direction.  Pyloric  tumours  are  distinguished 
by  an  examination  of  the  gastric  function  and  by  distension 
of  the  stomach.  An  ovarian  tumour  will  be  differentiated 
by  the  pelvic  connections  of  its  pedicle. 

INDICATIONS   FOR   OPERATION. 

The  indications  for  operation  in  movable  kidney  have 
been  with  reason  considerably  restricted  of  late  years, 
since  it  has  been  recognized  that  the  condition  is  often 
present  without  causing  any  inconvenience,  and  that 
many  symptoms  previously  ascribed  to  it  are  really  due 
to  affections  of  other  organs.  A  movable  kidney  in  itself, 
therefore,  constitutes  no  absolute  indication  to  operation. 


404  INDICATIONS    FOR    OPERATION    IN 

Formerly  also  movable  kidneys  have  been  removed,  but 
this  is  now  recognized  as  absolutely  inadmissible,  and  if 
operation  is  necessary  nephropexy  is  performed. 

Operation  is  required  when  the  patient  suffers  from 
severe  attacks  of  colic,  with  transient  or  persistent  retention, 
as  the  result  of  kinking  or  twisting  of  the  pedicle.  When, 
again,  a  patient  suffers  considerably  from  symptoms  which 
must  be  ascribed  to  a  movable  kidney,  and  when  there  is 
no  well-established  neuropathic  condition  present,  fixation 
of  the  kidney  by  suture  is  advisable,  provided  that  treatment 
by  diet,  apparatus,  and  hygienic  regime  has  been  tried  and 
failed. 

Contra-indications. — In  the  absence  of  the  more  serious 
symptoms  due  to  interference  with  the  renal  functions  by 
torsion  and  kinking,  operation  will  not  be  recommended 
until  other  treatment  has  been  tried.  If  a  nervous 
individual  attributes  a  whole  series  of  vague  troubles  to 
a  movable  kidney,  operation  should  not  be  done  simply 
because  she  desires  it,  because  the  suggestive  effect  of  such 
operation  is  often  of  very  transient  benefit.  Operation 
will  not  be  done  on  a  movable  kidney  when  there  is  some 
complicating  disease  of  the  digestive  or  genital  system, 
nor  is  it  advisable,  according  to  the  opinion  of  many 
surgeons  and  physicians,  when  the  condition  is  only  a  part 
of  a  general  enteroptosis. 

Prognosis. — Results  of  operation. — The  operative  mor- 
tality of  nephropexy  is  i"i8  per  cent  in  a  total  of  846 
cases ;  some  surgeons  have  had  a  mortality  of  3  per  cent. 
Kiister  has  reported  two  cases  of  pulmonary  embolism 
immediately  following  operation.  Nephrectomy  for  the 
condition  is  never  now  done ;  it  was  attended  by  a  large 
mortality,  more  than  25  per  cent  in  the  cases  published. 
Hcematuria,  albuminuria,  and  oliguria  have  been  described 
as  sequelae  of  the  operation,  and  in  a  few  cases  severe 
peritoneal  irritation,  post-operative  hsemorrhage,  and 
urinary  fistula.  In  several  instances  it  has  been  recorded 
that  the  opposite  kidney  has  subsequently  become  mobile. 

The  success  obtained  by  operation  is  not  entirely 
encouraging.  In  34  non-complicated  cases  85  per  cent 
were  cured,  but  in  47  complicated  cases  the  percentage 
was  only  44  ;  if  the  two  groups  are  combined  the  cases 
form    58    per    cent.     Satisfactory    results    are    especially 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     405 

obtained  when  the  condition  is  associated  with  some  nervous 
taint,  and  in  these  suggestion  no  doubt  plays  a  part.  In 
particular  the  immediate  result  is  good  in  these  cases,  but  the 
late  result  often  leaves  much  to  be  desired.  The  operative 
result  is  by  no  means  always  good,  and  in  the  hands  of  some 
surgeons  the  percentage  of  return  of  mobility  is  high. 

Without  operation. — In  many  cases  the  symptoms  can 
be  relieved  by  appropriate  palliative  treatment,  bandages, 
belts,  and  massage.  In  a  very  small  number  serious  com- 
plications sometimes  supervene,  such  as  hydronephrosis, 
new  growth,  and  calculi.  Death  from  collapse  or  peritonitis 
is  excessively  rare. 

LITERATURE. 

J.  Fischer.  Die  operative  und  die  nichtoperative  Therapie 
der  Wanderniere.  Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
Bd.  i.   1898 

BuDiNGER.  Ueber  Wanderniere.  Mitteil.  a.  d.  Grenzgebiete 
der  Med.  u.  Chir.     Bd.  ix. 

Israel.     Chirurg.   Klinik  de  Nierenkrankheiten.     Berlin.      1901. 

O.  Wyss.  2  Decennien  Nierenchirurgie.  Bruns'  Beitr.  z.  klin. 
Chir.     Bd.  xxxii. 

Senator.     Die  Krankheiten  der  Niere.     2nd  Ed.     Wien,  1903. 

WOLKOW   und    Delitzin.     Die   Wanderniere.      1899. 

KusTER.     Nierenkrankheiten.     Deut.     Chir.      1896. 

Albarran.     Traite  de  Chirurgie.     Tome  ii.     Paris,  1899. 


CHAPTER    XXIII. 

Diseases   of  the    Kidney    and    Renal    Pelvis 

{continued). 


409 


Chapter    XXIII. 

DISEASES    OF     THE    KIDNEY    AND    RENAL 
PELVIS    (contd.). 

TUMOURS    OF    THE    KIDNEY. 

Etiology. — Injury  and  calculous  disease  are  sometimes 
concerned  in  the  etiology  of  renal  new  growths.  The 
malignant  growths,  and  carcinomata  in  particular,  are 
comparatively  common  in  childhood  ;  more  than  a  third 
of  the  cases  of  carcinoma  and  two-thirds  of  the  cases  of 
sarcoma  belong  to  the  first  ten  years  of  life.  Renal  new 
growths  are  also  comparatively  frequent  between  the  ages 
of  50  and  70. 

Pathological  Anatomy.— Both  malignant  and  simple 
growths  occur  in  the  renal  tissue  ;  the  pelvis  is  the  seat 
of  origin  in  a  few  cases  only.  Primary  carcinoma  and 
sarcoma  usually  lead  to  enlargement  of  the  kidney,  but 
the  organ  may  be  destroyed  by  growth  without  notable 
increase  in  size.  Carcinoma  is  often  nodular  in  growth, 
and  the  tumour  may  present  to  the  touch  a  very  irregular 
outline  ;  the  growth  often  makes  its  way  into  the  venous 
channels,  and  may  extend  in  this  way  right  into  the  vena 
cava.  Some  forms  of  growth  are  less  nodular  than  infiltrat- 
ing in  character,  and  may  have  extended  to  a  considerable 
extent  into  surrounding  structures  before  any  tumour 
is  clinically  demonstrable.  The  lymphatic  glands  of  the 
neighbourhood  are  seldom  affected  ;  Israel  found  enlarged 
glands  in  only  7  out  of  44  cases  operated  on,  although 
several  were  considerably  advanced.  The  most  common 
type  of  carcinoma  appears  to  be  the  adenocarcinoma. 

Sarcomata  are  usually  round-celled  or  spindle-celled, 
and  may  be  single  or  multiple. 

Other  forms  of  malignant  growth  are  the  endothelioma 
and    perithelioma,  and    the    embryonal    adenosarcoma    of 


4IO  INDICATIONS    FOR    OPERATION    IN 

childhood.  The  hypernephroma  (Growitz)  is  sometimes 
simple,  sometimes  malignant.  Of  the  benign  growths,  for 
the  most  part  it  is  only  the  uncommon  lipomata  and 
fibromata  that  reach  large  dimensions.  Israel  computes 
that  70  per  cent  of  the  circumscribed  cases  develop  about 
the  lower  pole  and  the  middle  section  of  the  kidney. 

Clinically  the  aneurysms  of  the  renal  artery  have  been 
classed  with  the  tumours  ;  usually  they  are  small, 
occasionallv  very  large  ;  true  and  false  aneurysms  have 
been  described. 

Clinical  Course. — The  most  important  clinical  signs 
of  malignant  tumour  are  haematuria,  enlargement  of  the 
kidney  entirely  or  principally  of  solid  character,  pain,  and, 
later,  cachexia  and  metastasis.  Haematuria  is  often  the 
initial  symptom ;  it  occurs  as  such  in  a  fourth  of  all  cases, 
and  in  later  stages  is  present  in  a  half.  In  Israel's  cases 
early  haematuria,  with  or  without  colic,  was  present  in 
70  per  cent,  and  of  66  cases  only  5  had  no  haemorrhage. 
The  bleeding  is  sometimes  slight  and  infrequent,  sometimes 
first  follows  an  injury,  but  for  the  most  part  it  is  considerable 
and  even  profuse.  It  is  usually  symptomless,  has  no 
relation  to  exertion  or  position,  and  varies  extremely  in 
frequency.  In  one  of  my  cases  a  very  severe  haemorrhage, 
producing  marked  anaemia,  occurred  three  years  before  the 
appearance  of  a  tumour.  Usually  the  blood  is  passed 
mixed  with  the  urine,  sometimes  in  clots  which  may  cause 
colic  during  their  passage,  and  may  even  block  the  ureter 
and  cause  hydronephrosis,  though  this  is  rare.  The  urine 
may  show  no  abnormality  except  the  blood,  and  the  passage 
of  fragments  of  growth  is  unusual,  but  with  or  without 
blood  there  is  usually  albuminuria,  sometimes  of  advanced 
grade.  Casts  are  often  present,  coming  from  that  part  of 
the  kidney  involved  in  the  aseptic  inflammation  which 
accompanies  the  new  growth. 

Israel  describes  as  a  characteristic  sign  the  presence 
of  worm-like  coagula  enclosing  red  cells,  large  granular 
corpuscles,  atypical  epithelia,  and  detritus  derived  from 
destroyed  red  cells  in  a  fibrinous  ground  substance. 

In  the  later  stages  a  palpable  tumour  is  almost  always 
found ;  the  date  at  which  this  is  discovered  depends  upon 
the  skill  of  the  examiner  and  the  position  of  the  tumour 
in  the  kidne^^     Tumours  of  the  lower  pole  or  front  surface 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     411 

are  relatively  easily  felt  ;  examination  is  best  carried  out 
in  half  lateral  decubitus.  Malignant  tumours  are  as  a  rule 
irregular,  firm,  and  nodular,  and  often  tender  to  pressure. 
Israel  has  often  recognized  by  palpation  quite  small  tumours, 
down  to  the  size  of  half  a  cherry.  As  the  tumour  grows 
the  neighbouring  organs  are  pressed  upon  and  the  diaphragm 
may  be  pushed  upwards  ;  intestinal  resonance  is  found 
in  front  of  the  mass. 

In  about  a  quarter  of  the  cases  there  is  initial  pain  in  the 
kidney  region  and  along  the  course  of  the  ureter;  this  is 
sometimes  dull,  sometimes  most  intense.  On  the  side  where 
the  tumiour  is  situated  a  varicocele  often  develops,  some- 
times oedema  of  the  lower  limb  and  swelling  of  the  inguinal 
glands.  Fever  is  occasionally  present  ;  cachexia  appears 
late.  The  duration  of  the  disease  is,  in  children,  usually 
only  a  few  months,  seldom  a  year  ;  but  in  adults  it  is 
sometimes  prolonged  up  to  even  10  years,  with  a  mean  of 
about  2^.  The  course  is,  therefore,  more  prolonged  than 
is  usual  in  carcinoma  elsewhere  (Robert).  Death  occurs 
from  cachexia  or  haemorrhage,  rarely  from  uraemia  or 
rupture  of  the  kidney. 

Diagnosis. — In  presence  of  the  cardinal  symptoms — 
hsematuria,  tumour,  and  lumbar  pain — the  diagnosis  is 
easy  ;  intermittence  in  the  haematuria  is  a  helpful  sign, 
and  tumour  particles  may  be  found  in  the  urine.  Careful 
bimanual  examination,  distension  of  the  colon  and  of  the 
stomach,  examination  of  the  rectum  and  vagina,  radioscopy 
and.  cystoscopy,  will  decide  whether  a  tumour  is  renal  or  not. 

If  haematuria  is  the  first  symptom  diagnosis  must 
be  made  from  tuberculosis  and  calculus,  and  also  from 
hydronephrosis,  cystic  kidney  and  haemorrhagic  infarct. 
The  absence  of  tubercle  bacilli,  of  characteristic  nightly 
fever  and  perspirations,  and  the  negative  result  of  a  tuber- 
culin injection,  will  decide  against  tuberculosis.  Cystoscopic 
examination  of  the  ureteral  orifice  will  also  be  of  much 
assistance.  In  renal  stone  there  is  not,  as  a  rule,  a  large 
tumour,  colic  is  always  associated  with  the  haemorrhage  ; 
there  may  be  a  history  of  the  passage  of  calculi  previously, 
and  radioscopy  will  materially  assist.  Congenital  cystic 
kidney  is  often  associated  with  haematuria,  but  the  condition 
is  usually  bilateral,  whereas  new  growth  is  almost  always 
unilateral.     The   tumour  of  hydronephrosis   is   regular  on 


412  INDICATIONS    FOR    OPERATION    IN 

the  surface  and  elastic ;  it  is  rarely  associated  with  hcematuria 
in  any  quantity,  and  is  often  intermittent  and  varying 
in  size  from  time  to  time.  In  children  enlarged  retro- 
peritoneal glands  may  simulate  renal  tumour,  but  the 
absence  of  changes  in  the  urine  and  careful  examination 
will  not  fail  to  make  the  case  clear. 

INDICATIONS  FOR  OPERATION. 

If  the  presence  of  a  malignant  neoplasm  of  the  kidney 
has  been  definitely  ascertained  by  observation  of  the  cardinal 
symptoms,  or  if  the  question  amounts  only  to  a  great 
probability,  provided  that  the  other  kidney  is  functioning, 
operation  should  be  undertaken.  The  operation  is  explora- 
tory if  the  diagnosis  is  uncertain  ;  when  tumour  is  present 
total  extirpation  of  the  organ  is  the  rule.  There  are  cases 
in  which,  in  spite  of  the  presence  of  metastases,  operation 
is  still  indicated,  in  particular  when  profuse  haemorrhage 
threatens  life,  provided  that  cachexia  is  not  too  advanced. 
I  have  seen  one  case  where  this  indicatio  vitalis  called  for 
operation. 

Contra-indications. — If  metastases  are  present  (the 
skeleton  should  be  examined  for  them),  if  the  growth  is 
bilateral,  and  if  the  tumour  is  immovably  fixed  to  its 
surroundings,  operation  is  inadvisable.  Signs  pointing 
to  obstruction  of  the  vena  cava  inferior  also  negative 
operation,  because  they  indicate  that  the  tumour  has 
extended  to  this  channel.  Any  serious  complicating 
affection,  such  as  diabetes,  also  excludes  operation.  If 
fever  is  present  without  apparent  cause  it  is  against  opera- 
tion, because  it  only  occurs  in  renal  growths  when  they 
have  extended  beyond  the  limits  of  the  renal  capsule. 
Complete  absence  of  function  in  the  other  kidney  excludes 
operation,  but  not  if  the  function  is  only  in  part  interfered 
with,  as  by  amyloid  disease  or  chronic  nephritis ;  operation 
is  justifiable  under  such  circumstances  in  view  of  the  hope- 
lessness of  the  disease  without  it. 

Prognosis. — Results  of  operation. — The  end  results  of 
extirpation  for  tumour  are  unhappily  not  very  favourable. 
Israel  found  that  of  25  patients  who  had  survived  operation 
and  intercurrent  affections,  19  succumbed  to  recurrences  ; 
many  of  Israel's  cases  were  operated  on  at  comparatively 
early    stages.     Favourable    results    have,    however,    been 


.   DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     413 

obtained  in  many  cases.  At  the  least,  operation  improves 
the  patient  for  a  time,  relieves  him  of  pains,  and  may  enable 
him  to  return  to  work. 

Risks  of  operation. — Many  patients  operated  on  succumb 
to  heart  failure.  Among  43  of  Israel's  cases  5  died  from 
this  cause  and  4  from  some  other  condition  due  to  the 
operation.  According  to  Heresco  and  Israel  the  operative 
mortality  is  about  20  per  cent.  Disease  of  the  opposite 
kidney  is  relatively  rarely  the  cause  of  death. 

Without  operation. — Patients  with  malignant  disease  of 
the  kidney  inevitably  die  unless  rescued  by  surgery ;  yet 
the  duration  of  life  is  sometimes  as  much  as  several  years. 
It  is  not  very  unusual  for  such  patients  to  live  about 
four  years,  and  in  a  sixth  of  the  cases  the  period  actually 
extends  to  ten  years.  In  one  of  my  cases  seven  years 
elapsed  between  the  first  h^ematuria  and  death  ;  the  patient 
refused  operation  when  the  disease  was  in  its  early  stages. 

LITERATURE. 

Senator.  Krankheiten  der  Nieren.  2nd  Ed.  Nothnagel's  Hand- 
buch  der  spez.  Pathol,  u.  Therap.     Wien.      1903. 

ScHEDE.  Krankheiten  der  Nieren.  Handbuch  der  praktischen 
Chirurgie,  herausgegeben  v.  Bergmann,  Mikulicz,  u.  Bruns. 
Bd.  iii,  2nd  Ed.     Stuttgart :    F.  Ehke.      1903. 

V.  Hansemann.     Zeitschrift  fiir  klinische  Medizin.     Bd.  xliv. 

RovsiNG.  Die  Diagnose  und  Behandlung  der  bosartigen  Nieren- 
geschwiilste  beim  Erwachsenen.     Arch.  f.  klin.  Chir.     Bd.  li. 

Israel.     Chirurg.  Klinik  der  Nierenkrankheiten.     Berlin.      1901. 

Heresco.  De  ITntervention  Chirurgicale  dans  les  Tumeurs 
Malignes  du  Rein.     These  de  Paris.      1899. 

RosENSTEiN.  Die  Krankheiten  der  Niere.  Handbuch  der  prakt. 
Med.,  herausgegeben  v.  Ebstein-Schwalbe.  Stuttgart:  F.  Enke. 
1900. 


CYSTIC    KIDNEY. 

Etiology. — Cystic  kidney  is  a  congenital  affection  in  the 
majority  of  cases  ;  in  adults  it  is  usually  found  only  after 
maturity  ;  of  187  cases  two  only  belonged  to  the  second 
decennial  period.  Several  instances  have  been  recorded  of 
its  occurrence  in  more  than  one  member  of  a  single  family. 

Pathological  Anatomy. — It  is  almost  always  a  bilateral 
condition  in  congenital  cases  and  young  children.  In  older 
subjects  the  records  show  it  to  be  bilateral  in  about  four- 


414  INDICATIONS    FOR    OPERATION    IN 

fifths.  The  affected  organ  is  usually  much  enlarged  ;  it  is 
riddled  throughout  with  cysts  of  various  sizes.  It  may 
present  the  characteristic  renal  shape  or  may  form  an 
irregular-shaped  nodular  tumour.  The  cyst  contents  are 
sometimes  clear  and  yellow,  sometimes  turbid,  and  not 
infrequently  haemorrhagic.  In  a  third  of  the  cases  the  con- 
dition is  associated  with  cystic  disease  of  the  liver.  The 
causation  of  the  disease  has  been  ascribed  to  a  chronic 
inflammatory  change  ;  others  consider  it  of  the  nature  of  a 
malformation,  while  others  again  look  upon  it  as  due  to 
true  new  growth. 

Clinical  Signs. — Congenital  cystic  kidney  is  not  of 
much  surgical  importance  for  the  reason  that  most  of  the 
children  with  this  affection  die  early  from  pressure  on  the 
diaphragm  or  some  other  malformation.  In  adults  it  often 
runs  its  course  without  giving  rise  to  symptoms,  and  some- 
times is  found  accidentally  at  a  post-mortem  examination, 
as  in  two  cases  under  my  care  whose  urine  showed  no 
abnormality.  Occasionally  the  enlargement  is  so  marked 
that  it  can  be  recognized  by  palpation,  and  it  may  even  be 
possible  to  make  out  individual  nodular  cystic  swellings  on 
the  surface  of  the  tumour.  Pain  is  sometimes  a  symptom, 
sometimes  not  ;   occasionally  it  is  colicky  in  character. 

The  urine  is  often  normal,  but  sometimes  contains  albumin 
and  blood  in  quantity ;  it  may  also  contain  corpuscles  of 
rosette  shape,  or  resembling  leucin.  In  some  cases  the 
urine  is  like  that  of  chronic  interstitial  nephritis.  Explora- 
tory puncture  shows  that  the  bulging  nodules  contain  fluid, 
and  in  this  may  be  found  the  concentric  or  rosette-shaped 
bodies. 

In  many  cases  it  will  be  found  that  the  liver  is  enlarged 
and  it  may  be  possible  to  make  out  fluctuating  areas  in  it. 
Cardiac  hypertrophy  and  increased  arterial  tension  are  often 
present  ;  usually  the  general  condition  is  good,  but  there 
are  occasionally  digestive  troubles  and  fever.  The  latter 
usually  means  suppuration  in  the  cysts,  but  may  be  present 
without  it.  In  one  of  my  cases  there  were  frequent  rises 
of  temperature  without  apparent  cause,  and  the  autopsy 
revealed  no  focus  of  suppuration  to  account  for  them  ; 
possibly  they  were  due  to  uraemia. 

Severe  uraemic  attacks  are  common,  and  death  may  result 
from  this  cause. 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     415 

Diagnosis. — The  diagnosis  may  be  difficult.  It  is 
indicated  by  the  presence  of  a  bilateral  renal  tumour  with 
irregular  surface  and  fluctuating  areas,  particularly  if 
associated  with  periodic  hsematuria  and  with  simultaneous 
enlargement  of  the  liver  of  a  similar  type.  A  history  of  a 
similar  condition  in  some  other  member  of  the  family  should 
be  enquired  into.  The  rosette-shaped  corpuscles  appear  to 
be  diagnostic  of  the  condition  ;  they  are  apparently  found 
in  no  other  renal  affection. 

Hydatid  cyst  of  the  kidney  is  usually  unilateral,  and  the 
same  is  true  of  other  renal  tumours,  and  when  bilateral  the 
enlargement  of  both  kidneys  is  never  simultaneously  the 
same  as  may  be  the  case  in  cystic  disease. 

Differentiation  from  pyonephrosis  and  hydronephrosis 
may  be  very  difficult,  as  these  affections  may  be  bilateral, 
but  in  these  the  surface  of  the  tumour  is  smooth,  not  nodular, 
and  it  often  varies  in  size  from  time  to  time  and  may  be 
lessened  by  pressure. 

INDICATIONS  FOR  OPERATION. 

In  most  cases  surgical  intervention  is  inadvisable  owing 
to  the  bilateral  nature  of  the  condition.  In  exceptional 
instances  some  conservative  surgical  procedure  is  called  for  : 
nephrotomy  or  puncture  of  the  cysts.  The  circumstances 
which  may  call  for  this  are :  violent  or  continuous  pain  in  the 
loin  making  life  a  misery,  suppuration  in  the  kidney, 
copious  hsematuria,  and  sometimes  pressure  on  neighbouring 
organs  from  the  large  size  of  the  tumour.  If  anuria  super- 
venes it  forms  an  absolute  indication  for  operation  with  a 
view  to  relieving  tension. 

Prognosis. — Risks  of  operation. — Of  twenty-five  cases 
collected  by  Mohr,  seven  died  in  connection  with  the 
operation,  so  that  the  operative  mortality  appears  to 
be  high. 

Results  of  operation. — In  many  cases  anuria,  severe 
hsematuria,  and  suppuration  have  been  successfully  dealt 
with  by  operation.  In  unilateral  cases  the  removal  of  one 
kidney  has  been  successfully  performed  many  times,  but  in 
most,  cystic  degeneration  of  the  other  organ  has  followed 
after  a  varying  period.  It  must  be  remembered  that  cystic 
kidneys  which  are  apparently  in  an  advanced  state  of 
degeneration  are  often  functionally  active. 


4i6  INDICATIONS    FOR    OPERATION    IN 

LITERATURE. 

]MoHR.  Die  Behandlung  der  polycystischen  Nierenentartung. 
Mitteil  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  vi. 

Stiller.  Zur  Diagnostik  der  polycystischen  Nierenentartung. 
Berl.  klin.  Wochens.     P.  215.      1892. 

Senator.     Die  Krankheiten  der  Nieren.     2nd  Ed.     Wien.      1903. 

Israel.  Die  Chirurg.  Klinik  der  Nierenkrankheiten.  Hirsch- 
wald.     Berlin.      1901. 

ScHEDE.  Die  Krankheiten  der  Xieren.  Handbuch  der  prakt. 
Chir.     V.  Bergmann,  Bruns,  u.  ^Mikulicz.      2nd  Ed.      Wien,   1903. 


HYDATID    CYST    OF    THE    KIDNEY. 

Etiolosy. — Hydatid  cysts  are  most  frequent  between 
the  ages  of  20  and  30,  and  in  the  male  sex.  They  occur  less 
commonH'  in  the  kidney  than  either  the  liver  or  the  lung  ; 
in  Neisser's  900  cases  there  were  80  examples,  in  the  970 
cases  collected  by  Vegas  and  Cram  well  only  20. 

Pathological  i\NATOMY. — One  kidney  alone  is  affected 
in  almost  all  cases,  and  the  cyst  develops  in  the  cortex  of 
the  upper  or  lower  poles.  It  may  attain  large  dimensions 
and  causes  pressure  atrophy  of  the  surrounding  renal 
parenchyma  ;  but  even  in  the  case  of  very  large  cysts 
part  of  the  kidney  substance  always  remains  and  retains 
functional  capacity.  A  cyst  may  calcify  and  atrophy,  or 
may  suppurate.  The  latter  complication  may  produce 
serious  symptoms,  and  the  suppurating  cyst  may  perforate 
into  the  renal  pelvis,  the  pleura,  or  on  to  the  surface  in 
the  loin.  Rupture  into  the  renal  pelvis  is  common  with  or 
without  suppuration  (48  out  of  67  cases). 

Clinical  Course. — Small  cysts  are  often  present  without 
giving  rise  to  any  symptoms.  The  large  cysts  are  to  be 
felt  as  tumours  in  the  renal  region  ;  sometimes  they  appear 
solid,  in  other  cases  fluctuation  can  be  made  out.  Pressure 
on  the  tumour  is  usually  painless.  Sometimes  there  are 
subjective  pains,  and  if  vesicles  are  discharged  into  the  renal 
pelvis  and  block  the  ureter,  distinct  attacks  of  colic  result. 

The  urine  may  be  clear,  or  turbid  from  an  associated 
pyelitis,  or  it  may  be  mixed  with  cyst  contents.  In  the 
latter  case  it  is  turbid  and  more  or  less  milky,  or  may  con- 
tain blood  or  pus.  Such  an  alteration  in  the  urine  is  usually 
preceded  by  pain  of  a  colicky  character.  The  microscope 
will  show  the  presence  of  scolices  and  fragments  of  membrane, 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     417 

and  occasionally  whole  vesicles  are  discharged.  It  is  not, 
however,  in  every  case  that  such  direct  evidence  is  obtained 
in  the  urine  ;  a  kidney  may  contain  hundreds  of  vesicles 
and  yet  the  urine  may  show  no  characteristic  deposit.  If 
infection  takes  place  in  a  cyst,  high  fever  and  other  signs  of 
septic  absorption  supervene.  A  cyst  may  rupture  and 
discharge  vesicles  into  a  neighbouring  hollow  organ. 

Diagnosis. — Hydatid  cyst  of  the  kidney  will  be  diagnosed 
when  an  elastic  rounded  tumour  is  found  connected  with 
the  kidney,  associated  with  the  discharge  of  vesicles,  booklets, 
or  fragments  of  membrane  in  the  urine,  or  when  exploratory 
puncture  yields  a  clear  fluid,  poor  in  albumin,  rich  in 
chloride  of  sodium,  and  containing  succinic  acid.  The 
diagnosis  becomes  certain  if  the  tumour  subsides  simul- 
taneously with  the  discharge  of  vesicles. 

Hydatid  cyst  is  not  infrequently  mistaken  for  hydro- 
nephrosis and  solid  tumours,  and  the  diagnosis  may  be 
impossible  if  an  exploratory  puncture  cannot  be  made  and 
no  booklets  are  discharged  in  the  urine.  Regarding  the 
diagnosis  of  renal  swellings  in  general,  reference  should  be 
made  to  the  article  on  tumours  of  the  kidney. 

Renal  hydatid  may  simulate  ovarian  cystoma  ;  it  is  to 
be  distinguished  by  its  comparative  immobility,  and  by  the 
situation  of  the  bowel  in  front  of  and  to  its  inner  side  ; 
rectal  and  vaginal  examination  will  also  aid  in  the  differentia- 
tion. In  the  case  of  a  patient  under  my  care,  a  diagnosis 
of  ovarian  cyst  had  been  made  by  several  gynaecologists  ;  I 
saw  her  only  after  several  years'  illness  and  when  she  was 
in  extremis  ;  the  urine  was  turbid  and  milky,  and  hydatid 
membrane  was  found  in  it.  The  autopsy  showed  the 
presence  of  a  hydatid  ruptured  into  the  renal  pelvis,  the 
kidney  being  much  displaced  downwards. 

The  unilateral  character  of  the  condition  is  sufficient,  as 
a  rule,  to  distinguish  it  from  cystic  kidney. 

INDICATIONS  FOR  OPERATION. 

If  the  diagnosis  is  certain,  operation  should  be  undertaken 
without  delay  if  the  general  condition  admits  of  it.  If  the 
diagnosis  is  uncertain,  but  an  elastic  swelling  exists  in  the 
renal  region,  an  exploratory  operation  is  justified,  particu- 
larly if  fever  points  to  the  possibility  of  suppuration  in  the 
cyst,  or  a  rapid  increase  in  size  of  the  tumour  is  noted. 

27 


4i8  INDICATIONS    FOR    OPERATION    IN 

The  operation  usually  practised  is  incision,  with  suture  of 
the  cyst  wall  to  the  parietes. 

Contra-indications. — Considering  the  dangerous  nature  of 
the  disease,  and  the  relatively  slight  risks  attached  to 
operation,  there  cannot  be  said  to  be  any  contra-indications. 

Prognosis. — Risks  and  results  of  operation. — Since  incision 
has  become  the  practice  rather  than  removal,  the  risk  of 
the  operation  is  slight  relatively  to  the  serious  nature  of 
the  disease.  Of  twenty-three  cases  treated  by  incision  one 
died,  the  cause  being  heart  failure.  In  one  of  these  cases 
secondary  nephrectomy  was  necessary ;  the  remainder 
recovered  completely  without  further  intervention. 

Without  operation. — The  risks  attached  to  suppuration 
are  always  imminent.  Spontaneous  recovery  after  discharge 
into  the  urinary  channels  is  not  very  infrequent,  but  not 
sufficiently  common  that  it  can  be  relied  on. 

Reflex  anuria  may  be  induced  in  both  kidneys  if  one 
ureter  is  blocked  by  vesicles.  External  rupture  of  the  cyst 
may  give  rise  to  serious  complications.  On  the  other  hand 
it  must  be  noted  that  hydatid  cyst  of  the  kidney  may  be 
present  for  years  without  actually  endangering  life,  and 
that  escape  of  vesicles  through  the  urinary  channels  not 
infrequently  results  in  spontaneous  recovery. 

LITERATURE. 

Paul  Wagner.  Zur  Operation  des  Nierenechinococcus.  Centralb. 
f.  d.  Krankheiten  der  Harn-  und  Sexualorgane.      1894. 

Popper.  Echinococcus  der  Harnwege.  Berliner  klin.  Wochens. 
No.  9,  1898. 

HoNZEL.  Contribution  a  I'Etude  des  Kystes  Hydatiques  du  Rein. 
Revue  de  Chirurg.     1898. 

ScHEDE.  Echinococcus  der  Niere.  Handbuch  der  prakt.  Chir., 
herausgegeben  v.  Bergmann,  Mikulicz  u.  Bruns.  Bd.  iii,  2nd  Ed. 
Stuttgart.      1903. 

Senator.     Die  Krankheiten  der  Nieren.     2nd  Ed.     Wien.      1903. 

RosENSTEiN.      Krankheiten  der  Niere.    Handbuch  d.  prakt.  Med. 
herausgegeben  v.    Ebstein-Schwalbe.     Bd.   iii,     i     Teil.     F.    Enke. ' 
Stuttgart.      1900. 


HYDRONEPHROSIS  AND  PYONEPHROSIS. 

Etiology. — Hydronephrosis  may  occur  as  a  congenital 
affection,  or  may  be  acquired  after  birth.  Congenital 
hydronephrosis  is  due  to  some  malformation  or  to  intra- 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     419 

uterine  chronic  inflammatory  processes,  with  consequent 
atresia  of  the  urinary  passages.  Acquired  hydronephrosis 
may  be  due  to  obstruction  to  the  urinary  flow  either  by 
some  mechanical  cause  (tumour,  calculus,  foreign  body),  or 
by  adhesions  to  surrounding  structures  and  kinking  of  the 
ureter,  or  by  swelling  of  the  mucous  membrane  in  the 
narrower  portions  of  this  channel.  Pregnancy  and  a  floating 
kidney  are  both  predisposing  causes  to  the  condition.  In 
order  that  marked  hydronephrosis  may  occur  it  is  usually 
the  rule  that  the  obstruction  should  be  of  gradual  develop- 
ment or  intermittent  (Cohnheim). 

An  infection  in  some  part  of  the  body  may  secondarily 
cause  infection  of  a  hydronephrosis  by  way  of  the  blood 
stream.  Pyonephrosis  is  often,  however,  secondary  to  an 
infection  in  the  urinary  passages  below,  for  example,  cystitis, 
infection  by  catheterization,  ulcerating  tumours  of  the 
prostate  and  bladder,  etc.  Hydronephrosis  is  relatively 
common  in  childhood ;  pyonephrosis  is  rarely  found  before 
puberty. 

Pathological  Anatomy. — The  terms  hydronephrosis  and 
uronephrosis  Israel  applies  to  the  conditions  of  retention, 
which,  resulting  from  some  antecedent  obstruction  to  the 
urinary  flow,  are  at  first  aseptic  but  may  later  become 
infected.  The  term  pyonephrosis  he  applies  to  a  condition 
arising  in  direct  connection  with  an  infective  inflammatory 
process  without  antecedent  aseptic  retention,  the  inflamma- 
tory process  either  from  the  commencement  or  subsequently 
causing  the  retention.  Hydronephrosis  may  be  unilateral 
or  bilateral,  open  or  closed.  If  the  condition  is  advanced, 
the  altered  organ  presents  as  a  large  ovoid  elastic  tumour, 
with  contents  either  clear  or  turbid.  The  remains  of  the 
kidney  substance  is  set  laterally  on  the  ovoid  sac ;  the 
interior  often  presents  several  sacculations. 

The  most  frequent  causes  of  acquired  hydronephrosis  are 
changes  in  position  of  the  kidney,  renal  calculi,  tumours  of 
the  pelvis  (especially  uterine),  compression  of  the  ureters,  and 
inflammatory  swelling  of  the  mucous  membrane  of  the 
ureter.  In  a  pus  kidney  due  to  infection  of  a  hydronephrosis, 
the  ureter  is  thin-walled  and  usually  lengthened  and  in  part 
distended,  but  when  the  condition  is  due  to  a  primary 
ascending  infection  the  ureter  is  shortened,  thick-walled, 
and  often  shows  circumscribed  stenoses.     When  secondary 


420  INDICATIONS    FOR    OPERATION    IN 

to  hydronephrosis  the  tumour  is  often  very  large  and 
unilocular  ;  when  due  to  primary  infection  it  usualty  only 
reaches  moderate  dimensions  and  is  multilocular. 

Perinephritic  suppuration  often  takes  place  without  there 
being  any  actual  communication  between  the  perirenal 
abscess  and  the  interior  of  the  sac. 

Clinical  Course. — Hydronephrosis  often  develops  with- 
out giving  rise  to  symptoms.  The  most  important  sign  is 
a  tumour  recognized  as  involving  the  kidney.  Bimanually 
the  tumour  is  well  defined  and  as  a  rule  not  tender  to 
pressure ;  fluctuation  can  as  a  rule  be  made  out,  but  not 
always.  There  is  usually  a  tympanitic  note  on  percussion 
in  front.  The  size  may  vary  extraordinarily  from  time  to 
time  ;  the  kidney  may  be  mobile  or  immobile.  Rapid 
diminution  is  associated  with  evacuation  of  large  quantities 
of  urine  ;  while  occlusion  persists  there  is  usually  oliguria. 
The  evacuated  urine  is  sometimes  clear;  sometimes,  although 
large  in  amount,  it  is  turbid  from  admixture  with  mucus, 
pus,  or  blood.  Sometimes  casts  or  concretions  are  present. 
Persistent  polyuria  is  less  common. 

The  enlarged  kidney  often  causes  visible  bulging  in  the 
loin  ;  but  if  the  organ  is  mobile  the  bulging  will  be  in  the 
lower  part  of  the  abdomen  ;  even  when  hydronephrosis  is 
bilateral,  one  side  is  usually  larger  than  the  other.  Mobility 
on  respiration  is  almost  always  present,  though  it  may  be 
only  slight.  As  a  rule  the  patient  complains  of  a  sense  of 
fullness,  but  severe  spontaneous  pain  is  relatively  uncommon  ;. 
when  present  it  is  usually  of  a  colicky  character,  resembling 
the  pain  of  calculus.  If  it  occurs  in  this  form  the  affected 
kidney  is  usually  also  tender  to  pressure,  and  reflex 
inhibition  of  the  secretion  of  the  other  kidney  may  occur. 
Sometimes  when  a  hydronephrosis  develops  rapidly  it  is 
associated  with  fever  ;  fever  is  usual  in  pyonephrosis,  and 
may  be  intermittent,  continuous,  or  remittent.  Haemor- 
rhage may  occur  into  the  sac  during  the  stage  of  occlusion, 
so  that  the  urine  which  comes  away  after  the  attack  may 
be  haemorrhagic. 

In  intermittent  hydronephrosis  there  is  a  periodicity 
about  the  attacks  of  pain  and  the  enlargement  ;  once  the 
occlusion  has  become  permanent  the  pain  often  disappears. 
Uraemia  develops  if  the  function  of  the  other  kidney  fails. 
Occasionally    a    hydronephrotic    sac    ruptures,    either    in 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     421 

consequence   of  extreme   distension,   or  some   trauma  ;     if 
this  takes  place  there  is  great  pain  and  collapse. 

Cardiac  hypertrophy  is  only  occasionally  present. 

Diagnosis. — If  a  cystic  tumour  is  present  in  the  renal 
region,  and  there  is  tympanitic  bowel  in  front  of  it,  if 
cystoscopy  shows  that  no  urine  is  coming  from  one  ureter, 
and  no  other  condition  is  present  to  account  for  this,  the 
tumour  is  probably  a  hydronephrosis.  Absence  of  a 
tympanitic  note  in  front  of  the  swelling  does  not  exclude 
hydronephrosis ;  under  such  circumstances  artificial  disten- 
sion of  the  stomach  and  colon  may  be  of  assistance.  A 
tympanitic  area  will  be  present  between  the  tumour  and  the 
liver  or  spleen,  as  the  case  may  be.  If  the  tumour  diminishes 
either  spontaneously  or  under  palpation,  and  the  fluid 
empties  into  the  bladder,  the  diagnosis  is  practically  certain. 
Exploratory  puncture  is  risky,  and  does  not  give  any 
decisive  evidence. 

If  intermittent  fever  has  been  present  for  some  time,  and 
if  the  patient  passes  pus  in  considerable  quantities  from 
time  to  time,  pyonephrosis  must  be  diagnosed. 

Differentiation  from  other  cystic  tumours,  particularly 
of  the  kidney,  is  often  very  difficult.  Ovarian  cysts  have 
attachments  with  the  uterus  and  grow  upwards  from  the 
pelvis.  Other  cystic  renal  tumours  may  be  differentiated 
by  catheterization  of  the  ureter.  In  hydatid  cyst  scolices 
are  often  present  in  the  urine.  In  hepatic  and  splenic 
tumours  the  dullness  is  continuous  with  that  of  the  liver  and 
the  spleen.  A  hydronephrosis  may  move  freely  with 
respiration.  In  one  of  my  cases  the  free  mobility  on  respira- 
tion seemed  to  point  to  a  splenic  tumour,  until  pyuria 
cleared  up  the  diagnosis. 

Diagnosis  from  calculous  kidney  may  be  far  from  easy.  In 
both  conditions  there  may  be  attacks  of  colic  ;  in  hydro- 
nephrosis the  tumour  rapidly  increases  in  volume  during 
the  occlusion  stage,  and  red  blood-cells  are  absent  in  the 
intervals  of  the  attacks  of  colic,  whereas  they  occur  in  stone 
cases  after  exercise. 

A  distended  gall-bladder  can  usually  be  distinguished 
from  a  hydronephrosis  if  the  patient  is  placed  in  the  left 
lateral  position  ;  in  this  position  the  gall-bladder  passes 
towards  the  left  away  from  the  kidney. 


422  INDICATIONS    FOR    OPERATION    IN 

INDICATIONS  FOR  OPERATION. 

If  pyonephrosis  is  diagnosed  operation  is  indicated  with- 
out delay.  Nephrectomy  is  usually  necessary,  more  rarely 
nephrotomy. 

For  diagnostic,  and  above  all  for  palliative  purposes, 
puncture  of  a  hydronephrosis  may  be  indicated.  When 
sudden  occlusion  gives  rise  to  a  large  hydronephrosis,  with 
much  pain,  oliguria,  and  other  serious  symptoms,  if  a  more 
radical  operation  is  not  permissible,  puncture  with  drainage 
is  the  best  plan. 

In  cases  of  hydronephrosis  without  such  acute  symptoms, 
operation  is  called  for  when  there  is  persistent  long-continued 
pain,  when  non-surgical  treatment  of  the  cause  (e.g., 
bandaging  in  floating  kidney,  reposition  of  uterine  displace- 
ment) proves  useless  or  cannot  be  carried  out  for  some 
reason,  and  when  the  sac  cannot  be  completely  emptied  by 
massage. 

Torsion  of  the  pedicle  of  a  hydronephrosis  or  rupture  call 
for  immediate  intervention.  In  occlusion  with  reflex  anuria 
or  oliguria,  intervention  is  equally  justified,  since  continuous 
catheterization  of  the  ureter  is  dangerous. 

Operation  will  be  designed  to  deal  with  the  cause  of  the 
retention,  and  the  kidney  will  be  extirpated  only  if  it  is 
very  large,  if  the  parenchyma  is  atrophied,  if  the  ureter 
is  obliterated,  if  the  cause  is  an  inoperable  tumour 
situated  in  the  pelvis,  and  if  conservative  methods  prove 
useless.  Nephrectomy  is  of  course  only  justifiable  when 
one  is  certain  that  a  second  and  functioning  organ  is 
present.  To  be  sure  of  this  it  is  necessary  to  obtain  the 
urine  from  each  side.  If  only  one  organ  is  secreting,  i.e., 
that  on  the  apparently  healthy  sid§,  it  is  necessary  to 
examine  its  molecular  concentration  and  the  amount  of 
urea.  The  phloridzin  test  is  also  of  importance  ;  5  mgr. 
of  phloridzin  are  injected  subcutaneously,  and  the  amount 
of  sugar  secreted  is  measured.  The  less  the  functional 
capacity  of  the  kidney,  the  less  urea  is  excreted,  and  the  less 
sugar  is  passed  after  phloridzin  injection. 

External  circumstances,  such  as  the  patient's  position, 
may  contra-indicate  conservative  methods,  and  point  to  the 
advisability  of  radical  operation. 

Contra-indications. — Against    operation    will    be    hydro- 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.    423 

nephrosis  of  both  kidneys,  the  presence  of  some  pernicious 
inoperable  causative  disease,  such  as  uterine  cancer, 
defective  functional  capacity  of  the  second  kidney,  or  the 
complete  absence  thereof. 

In  bilateral  primary  pyonephrosis  any  serious  operative 
interference  is,  as  a  rule,  contra-indicated. 

Prognosis. — Without  operation. — There  is  often  insupport- 
able pain,  sensations  of  distension,  and  frequent  renal 
haemorrhage.  In  the  case  of  large  tumours  there  is  the  risk 
of  rupture ;  in  hydronephrosis  of  a  floating  kidney  the  pedicle 
may  become  twisted.  There  is  always  the  risk  of  a  secondary 
infection  in  a  case  of  hydronephrosis.  Pyonephrosis  may 
prove  fatal  from  septic  intoxication,  or  from  spread  of  the 
inflammatory  condition  to  other  structures  around. 

Risks  of  operation. — Of  forty  cases  of  aseptic  and  infected 
hydronephrosis  operated  on  by  Israel,  five  died,  three  of 
these  after  primary  nephrectomy.  The  operative  mortality 
of  pyonephrosis  is  still  higher  :  a  third  of  Israel's  cases 
succumbed.  According  to  this  surgeon  this  is  to  be 
explained  by  the  frequency  of  bilateral  infection,  by  the 
small  resistance  of  the  primarily  infected  kidney  to  the 
infection,  by  the  failure  of  compensatory  hypertrophy  of 
the  other  kidney,  and  finally  by  the  fact  that  pyonephrosis 
is  most  common  at  a  relatively  advanced  age  (the  ages  of 
half  of  his  cases  lay  between  50  and  70). 

Results  of  operation. — Of  Israel's  40  cases,  32  were  entirely 
cured  by  operation,  3  relieved.  In  19  cases  of  true  primary 
pyonephrosis,  the  same  surgeon  obtained  a  complete  cure 
in  58-8  per  cent  of  those  treated  by  primary  or  secondary 
nephrectomy,  in  only  5 '2  per  cent  when  conservative 
methods  were  employed.  In  many  cases  treated  by 
conservative  methods,  particularly  by  incision  for  pyone- 
phrosis, a  urinary  fistula  persisted  which  necessitated 
nephrectomy  later. 

LITERATURE. 

Senator.  Die  Nierenkrankheiten.  2nd  Ed.  Wien.  1903. 
Nothnap;crs  Handbuch  d.  spez.   Pathol,  u.  Therap. 

Israel.  Chirurgische  Klinik  der  Nierenkrankheiten.  BerUn. 
1901. 

Wagner.  Behandhing  der  Nierenkrankheiten.  Handbuch  d. 
spez.  Therap.,  herausgegeben  v.,Penzoldt-Stintzing.      3rd  Ed. 

Navarro.     Contribution  a  I'Etude  de   I'Hydronephrose.     These 


424  INDICATIONS    FOR    OPERATION    IN 

de  Paris.  1899.  Societe  de  Chirurgie  de  Paris.  1901.  Bary, 
Albarran. 

GossET.  Traitement  des  Retentions  Renales.  Rev.  de  Chir. 
1900. 

Boucher.  Intermittent  Hydronephrosis.  New  York  Med.  Jour., 
Vol.  Ixxvi,  No.  8. 

C.  Adriasj.  Diagnostische  Bedeutung  des  Ureterenkatheterismus. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir ,  1902. 


TUBERCULOSIS    OF    THE    KIDNEY. 

Etiology. — Tuberculosis  of  the  kidney  may  arise  from 
infection  by  way  of  the  blood  stream,  or  from  the  urinary 
channels  below.  Sometimes  the  kidney  is  the  only  organ 
in  the  body  showing  tubercular  infection  ;  that  is  to  say, 
primary  renal  tuberculosis  occurs.  The  acute  form  of  the 
disease  is  most  common  in  children,  the  ascending  form  of 
chronic  tubercle  in  men  between  twenty  and  forty,  the 
primary  disease  in  women.  Tubercular  foci  in  some  part 
of  the  male  sexual  organs  is  not  uncommonly  an  antecedent 
of  a  secondary  renal  invasion. 

Pathological  Anatomy. — There  are  two  chief  anatomical 
types,  the  acute  disseminated  and  the  chronic.  The  chronic 
type  is  often  unilateral  in  the  early  stages,  affects  the  left 
kidney  more  frequently  than  the  right,  and  not  uncommonly 
finds  its  seat  towards  the  lower  pole.*  Fairly  large  caseous 
foci  are  produced  in  this  way  which  tend  to  break  down.  In 
advanced  stages  the  greater  part  of  the  renal  parenchyma 
is  often  destroyed  ;  the  kidney  is  then  enlarged  as  a  whole. 
The  renal  pelvis  and  ureter  are  frequently  invaded,  and  as 
the  disease  extends  downwards  the  bladder  becomes  involved, 
in  the  first  place  round  about  the  ureteral  orifices.  Israel 
records  secondary  bladder  tuberculosis  in  40  per  cent  of  his 
cases.  The  disease  may  spread  through  the  renal  capsule 
and  involve  neighbouring  structures. 

It  is  a  fact  of  great  practical  importance  that  unilateral 
primary  tuberculosis  does  occur  without  any  other  discover- 
able tubercular  lesion  in  the  body. 


*  Israel  speaks  of  three  types  of  the  chronic  disease  :  (i)  The  most 
common  —  the  caseous-excavating  type  from  which  pyonephrosis  may 
develop  by  mixed  infection;  (2)  Tubercular  ulceration  of  the  apices  of 
the  papillae  ;   (3)  The  chronic  disseminated  nodular  typ3. 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     425 

In  other  cases  autopsy  has  shown  the  bladder  disease  to 
be  of  old  standing  and  extensive,  the  ureteral  and  renal 
infection  being  recent  and  at  an  early  stage. 

Clinical  Course. — The  disease  often  remains  latent  for 
a  long  period.  The  symptoms  of  chronic  renal  tuberculosis 
are  general  and  local.  Sometimes  the  general  symptoms 
make  their  appearance  before  the  local :  loss  of  appetite  and 
power  of  digestion,  increasing  anaemia,  wasting,  hectic  fever 
(especially  if  the  bladder  is  involved),  and  profuse  sweating. 
As  a  rule  other  localizing  symptoms  co-exist  with  these  : 
disturbances  of  micturition  and  changes  in  the  composition 
of  the  urine.  The  patient  passes  water  more  frequently  than 
usual,  and  sometimes  complains  of  tenesmus  or  uncomfort- 
able sensations  after  the  act.  Blood  and  pus  are  usually 
present  in  the  urine,  and  not  infrequently  mucopurulent 
masses  and  shreds  ;  the  reaction  remains  acid.  Hematuria 
is  often  the  first  symptom,  and  supervenes  independently  of 
exercise  or  exertion.  Tubercle  bacilli  are  to  be  demonstrated 
in  the  urinary  sediment  in  about  a  third  of  the  cases  only. 
Casts  are  not  common,  and  albumin  is  usually  present  only 
in  small  quantities.  There  is  as  a  rule  a  complaint  of  pain, 
either  constant  or  intermittent  ;  it  may  be  confined  to  the 
loin  or  may  radiate  towards  the  bladder  and  the  thigh. 
Sometimes  it  is  of  a  colicky  character.  Severe  pain  during 
micturition  is  almost  entirely  confined  to  cases  where  the 
tuberculosis  has  invaded  the  ureter  and  bladder. 

The  affected  kidney  can  usually  be  palpated  and  its 
enlargement  noted  (19  times  in  24  of  Israel's  cases), 
particularly  if  the  surrounding  tissues  are  involved  in  the 
inflammatory  changes  or  if  a  hydronephrosis  is  associated 
with  the  tubercular  lesion.  Tenderness  on  palpation  is 
slight  unless  there  is  acute  suppurative  perinephritis. 

The  duration  of  the  disease  is  seldom  more  than  five  years 
from  the  appearance  of  the  first  symptoms  until  death. 
The  propagation  of  the  disease  from  kidney  to  bladder 
may   occur   at   any   stage   of   the   disease. 

Diagnosis. — The  discovery  of  tubercle  bacilli  in  the  urine 
(to  be  distinguished  from  the  smegma  bacillus),  may  make 
the  diagnosis  certain  ;  but  even  without  this  a  definite 
diagnosis  can  usually  be  made. 

If  a  unilateral  renal  disease  is  present,  and  the  cystoscope 
shows  evidence  of  tuberculosis  limited  to  the  ureteral  papilla 


426  INDICATIONS    FOR    OPERATION    IN 

or  its  immediate  neighbourhood,  it  is  clear  that  the  disease 
is  descending.  Any  purulent  renal  affection  should  raise 
a  suspicion  of  tubercle  ;  according  to  Israel  a  third  of  all  pus- 
forming  processes  in  the  kidney  are  tubercular  in  nature. 

In  all  cases  of  rebellious  cystitis  also,  tubercle  should  be 
suspected  ;  an  evening  rise  of  temperature,  night  sweats, 
tubercular  lesions  elsewhere,  especially  in  the  genitals,  pallor, 
loss  of  appetite,  renal  pain,  occasional  hsematuria  and  colic 
are  sufficient  to  make  the  diagnosis  clear,  even  if  no  tubercle 
bacilli  can  be  found. 

If,  after  an  injection  of  tuberculin  (^-i  mgram  of  the  old 
tuberculin),  there  is  pain  in  the  kidney,  hsematuria,  and 
tubercle  bacilli  in  the  urine,  the  diagnosis  is  also  established. 

The  condition  of  the  other  kidney. — Before  deciding  on 
operation  it  is  most  important  to  have  precise  information 
about  the  other  kidney.  If  urine  is  obtained  from  this  side, 
and  more  than  traces  of  albumin  are  found  in  it,  it. may  be 
concluded  that  it  is  affected  in  some  manner.  A  large 
quantity  of  albumin  indicates  a  grave  renal  lesion  if  the 
heart  is  sound  ;  a  small  quantity,  however,  does  not 
necessarily  mean  a  slight  lesion.  A  lesion  in  this  kidney 
may  be  actual  tuberculosis,  or  waxy  disease,  or  some 
accidentally  associated  condition,  such  as  stone,  or  there 
may  be  simply  a  toxic  nephritis  of  a  relatively  benign  type, 
subsiding  rapidly  when  the  other — the  tubercular — organ 
is  removed.  If  tubercle  bacilli  are  found  in  the  urine  from 
this  side  it  will  of  course  point  to  an  actual  tuberculosis 
here  also  ;  leucocytes,  casts,  and  other  pathological  elements 
will  not  show  whether  the  condition  is  actually  tuberculous 
or  waxy,  or  merely  a  toxic  nephritis,  and  neither  will 
cryoscopy  and  the  phloridzin  test  give  any  absolutely 
reliable  information  on  this  point.  These  difficulties  must 
be  taken  into  account  when  the  question  of  surgical  treat- 
ment comes  to  be  decided. 

Differential  diagnosis. — The  diagnosis  from  an  infected 
nephrolithiasis  is  specially  important.  The  history  of  the 
passage  of  gravel  or  calculi  previously,  repeated  colic, 
absence  of  tubercular  lesions  in  other  organs,  and  of  tubercle 
bacilli  in  the  urine,  and  examination  with  the  X-rays,  are 
usually  sufficient  to  demonstrate  the  presence  of  calculus. 
Pyuria  is  not  a  common  sign  in  new  growths,  and  sometimes 
fragments  of  growth  are  to  be  found  in  the  urine.     If  the 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.    427 

alterations  in  the  urine  and  in  the  act  of  micturition  are  very- 
pronounced  it  is  sometimes  difficult  to  distinguish  tubercle 
from  pyelitis.  If,  however,  fever  is  constantly  present,  if 
the  kidney  is  not  particularly  tender  to  pressure,  and  if  the 
urine  is  only  slightly  turbid,  tuberculosis  is  the  more 
probable.  The  tuberculin  reaction  is  also  available  as  a 
means  of  differentiation,  as  has  already  been  remarked. 

In  a  female  patient  under  my  care,  with  tuberculosis  of 
the  bladder,  an  acute  h^emorrhagic  nephritis  supervened 
and  gave  rise  to  a  suspicion  of  renal  tuberculosis  ;  the 
presence  of  numerous  casts,  however,  were  against  a  chronic 
tuberculosis,  and  the  autopsy  showed  that  the  kidney  was 
free  from  tuberculous  infection. 

INDICATIONS  FOR  OPERATION. 

Surgical  treatment  consists  for  the  most  part  of  total  or 
partial  nephrectomy.  The  evacuation  of  confined  pus  and 
broken-down  tissue  by  nephrotomy  is  more  rarely  indicated. 
The  indications  for  operation  vary  somewhat  according  to 
the  stage  of  the  disease.  If  one  is  fortunate  enough  to  be 
able  to  diagnose  a  unilateral  renal  tuberculosis  in  the  early 
stages,  it  is  justifiable  to  institute  a  general  expectant 
treatment  if  the  surroundings  of  the  case  are  favourable,  and 
no  severe  general  or  local  symptoms  are  present.  If  serious 
symptoms  supervene,  surgery  must  be  resorted  to,  and  it 
is  in  this  way,  rather  the  complications  of  the  disease  than 
the  disease  itself,  which  make  operation  urgent.  Colic,  fever, 
hsemorrhages,  pyuria,  retention  processes,  vesical  pains, 
loss  of  flesh  and  appetite  :  these  are  the  signs  which  call  for 
intervention.  If  cystoscopy  shows  the  disease  extending  to 
the  ureteral  papilla,  nephrectomy  is  definitely  indicated. 
The  same  is  true  when  a  primary  renal  tuberculosis  is 
recognized,  already  well  advanced  and  associated  with  fever, 
loss  of  flesh,  anaemia,  and  night  sweats,  and  the  disease 
appears  to  be  probably  confined  to  one  side. 

A  primary,  unilateral,  renal  tuberculosis  should  also  be 
operated  on,  even  if  the  vesical  mucous  membrane  is 
extensively  involved.  If  a  perinephritic  tubercular  abscess 
is  present  which  has  originated  from  the  kidney,  it  must  be 
opened  and  nephrotomy  performed.  If  the  disease  is  of 
the  ascending  type,  operation  is  only  indicated,  according  to 
Israel,  when    the    renal    disease    gives  rise   to   special  and 


428  INDICATIONS    FOR    OPERATION    IN 

severe  symptoms,  or  when  the  retention  of  pus,  fever, 
anaemia,  and  disorders  of  nutrition  are  breaking  down  the 
patient's  powers  of  resistance. 

Contra-indications. — Serious  comphcations  in  other  organs, 
and  particularly  serious  tubercular  lesions  in  lungs,  bones, 
and  glands,  contra-indicate  surgical  intervention,  as  does 
also  any  well-established  disease  in  the  other  kidney.  It 
has  already  been  remarked,  that  it  is  impossible  to  be  certain 
whether  disease  in  the  other  kidney  is  of  a  slight  (toxic)  or 
of  a  severe  type  in  cases  where  the  urine  from  this  side 
contains  little  albumin  and  no  tubercle  bacilli  ;  but  if  this 
urine  contains  much  albumin,  or  renal  elements  in  quantity, 
or  pus,  or  tubercle  bacilli,  operation  is  correspondingly 
inadvisable.  On  the  other  hand,  a  slight  amount  of  albumin 
and  scanty  renal  elements  does  not  contra-indicate  operation 
when  the  disease  on  the  other  side  is  pronounced. 

The  methods  of  investigating  renal  function  by  cryoscopy 
and  the  phloridzin  test  do  not  give  such  certain  results  that 
they  should  be  considered  indispensable  in  deciding  the 
question  (Israel).  Secondary  tuberculosis  of  the  bladder, 
unless  advanced,  is  no  contra-indication  to  nephrectomy, 
as  experience  has  shown  that  this  usually  improves  after 
removal  of  the  kidne}^ 

When,  however,  a  primary  bladder  tuberculosis  is  associ- 
ated with  advanced  disease  in  one  kidney,  and  the  other  is 
not  entirely  healthy,  even  when  the  albumin  from  the  latter 
is  small  in  quantity,  operation  is  not  advisable,  because 
primary  bladder  tuberculosis  is  usually  followed  by  tuber- 
culosis of  the  kidney  on  both  sides. 

Prognosis. — Risks  and  results  of  operation. — Israel  has 
recorded  22  cases  of  primary  renal  tuberculosis  (8  with 
secondary  disease  in  the  bladder)  ;  16  were  permanently 
cured  by  operation,  and  four  died  either  immediately  after 
or  later.  Of  8  cases  of  secondary  renal  tuberculosis 
or  combined  renal  and  vesical  disease  in  which  the 
primary  seat  was  unknown,  3  were  cured  and  5  died. 
The  same  surgeon  estimates  the  mortality  of  nephrectomy 
for  tuberculosis  at  28'5  per  cent.  The  risk  of  the 
operation  is  therefore  considerable.  If  the  operation 
is  successful  recovery  may  be  complete ;  cases  are  on 
record  of  perfect  health  eight  years  later.  A  toxic 
nephritis    of     the    opposite     kidney    may    also    disappear 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     429 

completely  after  removal  of  the  tuberculous  organ.  Even 
vesical  tuberculosis  may  disappear  after  nephrectomy,  if  not 
advanced. 

Without  operation. — Spontaneous  recovery  is  exceptional, 
and  occurs  only  when  the  disease  focus  is  of  small  dimensions. 
Once  the  disease  has  given  rise  to  symptoms  it  progresses, 
unless  the  kidney  is  removed,  and  slowly  but  surely  leads 
to  marasmus  and  death. 

LITERATURE. 

Senator.  Die  Nierenkrankheiten.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Therap.     2nd  Ed.  .  Wien,  1903. 

Israel.  Chirurgische  Klinik  der  Nierenkrankheiten.  Berlin, 
1901. 

ScHNURER.  Die  primare  Nierentuberkulose.  Kritisches  Sammel- 
referat.     Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1899. 

KusTER.  Die  chirurgischen  Krankheiten  der  Niere.  Deut. 
Chir.     Bd.    lii.     Stuttgart. 

Wagner.  Die  Behandlung  der  Nierenkrankheiten.  Handbuch 
d.  spez.  Therap.  v.  Penzoldt-Stintzing.     Bd.  vii. 

Leyden.  Die  Diagnose  der  Nierentuberkulose.  Berliner  klin. 
Wochens.,  No.   17.     1896. 

Kapsammer.  Flint  geheilte  Falle  von  Nieren-  und  Blasentuber- 
kulose.     Wiener  klin.   Wochens.,   No.    16,    1904. 

Albarran,  Bary,  Delbet,  Kirmisson,  Tuffier,  Routier, 
Vortrage  von.     Societe  de  Chirurgie  de  Paris,  1899,  1900,  1901. 

Bezaguet.     Tuberculose    Renale.     These   de   Paris,    1898. 


PYELITIS   AND    SUPPURATIVE    NEPHRITIS. 

Etiology. — Suppurative  renal  affections  are  more 
frequently  met  with  in  adults  than  in  children,  and  in  men 
than  in  women.  Pyelitis  is  often  caused  by  the  presence  of 
some  foreign  body  in  particular  calculi,  more  rarely  new 
growths  and  parasites;  it  also  occurs  from  ascending 
infection  from  the  bladder,  and  also  from  the  action  of 
irritant  diuretics.  Venous  engorgement,  injury,  and 
adjacent  inflammatory  lesions  (either  in  the  renal  paren- 
chyma or  the  surrounding  tissues)  are  all  of  etiological 
importance.  Suppurative  nephritis  also  occurs  by 
metastasis  from  some  septic  focus  elsewhere  in  the  body, 
and  supervenes  sometimes  in  the  course  of  certain  of  the 
acute  exanthemata  :   variola,  scarlatina,  and  typhoid. 

Pathological    Anatomy. — Suppurative    nephritis    may 


430  INDICATIONS    FOR    OPERATION    IN 

be  secondary  to  infection  conveyed  upwards  from  the 
urinary  passages  or  conveyed  by  the  blood  stream,  or  it  may 
result  from  an  inflammatory  affection  of  neighbouring 
structures  or  a  penetrating  wound.  In  haematogenous 
infection  the  original  focus  is  often  in  the  lower  urinary 
passages,  or  may  be  in  some  distant  part  of  the  body.  The 
disease  is  more  frequently  unilateral  than  bilateral,  not  only 
when  calculus  is  the  cause,  but  also  in  ascending  infections. 

Acute  catarrhal,  chronic  catarrhal,  purulent  and  ulcerative 
forms  are  recognized,  the  ulceration  in  the  last  being  often 
very  destructive.  If  the  escape  of  the  urine  is  prevented  in  a 
case  of  pyelitis,  the  condition  becomes  one  of  pyonephrosis. 
The  inflammatory  condition  of  the  pelvis  often  extends  to 
the  parenchyma,  and  abscesses  develop  frequently  in  large 
numbers. 

A  purulent  pyelonephritis  may  be  the  precursor  of 
perinephritic  abscess.  When  a  renal  abscess  develops 
irom  blood  infection,  the  secondary  involvement  of  the  renal 
pelvis,  if  it  occurs,  is  usually  not  of  a  pronounced  character. 
Abscesses  originating  in  this  way  may  be  multiple ;  by 
confluence,  cavities  of  considerable  size  may  develop,  and 
tend  to  make  their  way  through  the  capsule.  Such  abscesses 
are  often  entirely  shut  off  from  the  renal  pelvis  and  urinary 
passages. 

Clinical  Course. — In  cases  of  pyelitis  the  urine  is  turbid, 
often  purulent,  and  sometimes  bloody.  If  the  renal 
parenchyma  is  not  involved  the  amount  of  albumin  is  small ; 
n  pyelonephritis,  on  the  other  hand,  both  albumin  and  casts 
are  present  in  the  urine.  If  discharge  from  the  kidney  is 
obstructed  the  urine  may  be  quite  clear,  coming  from  the 
opposite  kidney  alone  ;  in  such  a  case  the  diseased  organ 
will  be  enlarged,  painful,  and  tender  to  pressure,  signs  which 
subside  if  the  obstruction  disappears,  and  the  urine  again 
becomes  turbid. 

In  acute  pyelitis  the  amount  of  urine  is  often  diminished, 
and  sometimes  there  is  marked  tenesmus  ;  even  in  cases 
where  the  opposite  kidney  is  sound,  reflex  anuria  may 
develop.  In  renal  abscesses  following  blood  infection  the 
amount  of  urine  is  often  lessened,  and  albumin  and  renal 
elements  are  present  in  quantity.  In  such  a  case  pyuria 
occurs  when  the  abscess  ruptures  into  the  renal  pelvis,  and 
the  fever  and  pain  then  often  subside  simultaneously.      If  a 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.     431 

parenchymatous  inflammation  is  associated  with  pyehtis, 
casts  of  various  kinds  will  be  present  in  the  deposit.  If, 
however,  an  abscess  is  encapsuled  in  the  kidney  substance 
the  urine  may  be  normal  in  every  respect. 

Pains,  sometimes  of  a  distinct  colicky  character,  are 
frequent  in  acute  pyelitis  ;  in  the  chronic  disease  they  are 
only  present  when  some  obstruction  occurs  to  the  emptying 
of  the  renal  pelvis.  In  acute  purulent  nephritis,  pain  and 
tenderness  on  palpation  are  usually  very  acute,  and  the 
same  is  true  of  traumatic  suppurative  nephritis.  In  the 
latter,  hsematuria  and  rigors  are  common,  and  sometimes 
reflex  anuria.  Fever  is  the  rule  in  acute  pyelitis,  and  occurs 
in  the  chronic  disease  when  there  is  absorption  of  the 
infective  products.  A  palpable  tumour  is  to  be  felt  in 
pyelonephritis  only  when  retention  occurs. 

In  acute  renal  abscess  fever  is  often  high  and  sustained  ; 
in  the  subacute  and  chronic  abscess  it  is  often  present  in 
an  intermittent  form,  with  rigors  and  sweating,  but  is 
sometimes  absent  altogether.  In  acute  abscess  the  patient 
usually  loses  strength  rapidly,  and  enlargement  is  commonly 
to  be  made  out,  as  well  as  tenderness. 

When  an  ascending  inflammation  invades  the  kidney  the 
amount  of  urine  is  diminished  and  the  amount  of  pus 
increased.  The  opposite  kidney  is  often  affected  with  a 
toxic  nephritis  or  with  amyloid  disease  in  the  chronic  cases. 

Diagnosis. — Pyelitis  will  be  diagnosed  when  pus  is 
present  in  the  urine  but  there  is  no  disturbance  of 
micturition,  when  there  are  no  casts  and  only  traces  of 
albumin,  when  one  of  the  kidneys  can  be  felt  as  a  tender 
swelling  in  the  loin,  and  when,  after  washing  out  the  bladder, 
purulent  urine  is  withdrawn  by  catheter  after  pressure  on 
the  swelling. 

The  diagnosis  is  established  if  the  cystoscope  shows  pus 
coming  from  one  ureter,  whether  the  bladder  is  healthy  or 
not.  If  the  signs  point  to  pyelitis,  and  at  the  same  time 
there  are  numerous  casts  and  much  albumin  in  the  urine, 
the  diagnosis  will  be  pyelonephritis. 

Hiematogenous  renal  abscess  with  subsequent  rupture 
into  the  renal  pelvis  is  usually  to  be  recognized  from  the 
presence  of  some  infective  focus,  an  acute  commencement 
with  rigor,  high  fever,  local  sweHing  and  tenderness,  and  the 
sudden  appearance  of  pus  and  often  blood  and  renal  elements 


432  INDICATIONS    FOR    OPERATION    IN 

in  the  urine.     The  enlargement  of  the  kidney  is  the  sign  of 
most  importance. 

The  conditions  which  may  be  confused  witli  a  pyehtis  are 
tumours  of  kidney,  hver,  spleen,  ovary,  and  intestine. 
Repeated  bimanual  examination  is  of  special  value,  under 
anaesthesia  if  necessary.  If  the  intestine  is  inflated  a  renal 
swelling  is  found  to  be  behind  the  colon,  and  below  and 
behind  an  inflated  stomach.  Pelvic  examination  will 
exclude  ovarian  tumours.  Inflation  of  the  colon  will  show 
up  a  liver  or  splenic  tumour.  If  the  tumour  subsides 
coincidently  with  the  appearance  of  pus  in  the  urine,  this 
will  aid  the  diagnosis.  If  there  is  a  fistula  in  the  loin,  and 
methylene  blue  is  injected  into  this,  it  will  be  seen  within  a 
minute  issuing  from  the  ureter.  Pus  with  a  urinous  odour 
may  be  found  with  an  exploring  syringe,  but  such  an 
exploration  must  not  be  done  unless  preparations  are  made 
to  operate  at  once. 

INDICATIONS  FOR  OPERATION. 

The  discharge  of  pus  from  one  kidney  is  an  indication  for 
operation,  whether  the  suppuration  is  the  consequence  of  an 
ascending  infection,  a  direct  renal  trauma,  the  spread  of  an 
inflammatory  condition  from  surrounding  structures,  or  a 
blood-borne  infection.  High-fever,  rigors  and  sweating,  and 
other  acute  signs  indicate  the  necessity  for  immediate 
intervention,  even  in  cases  where  the  inflammatory  condition 
is  chiefly  but  not  exclusively  unilateral.  In  every  case  it  is 
necessary  to  ascertain  whether  there  are  two  ureters  opening 
into  the  bladder,  and  which  is  the  one  discharging 
urine ;  also  as  much  as  possible  about  the  functional 
capacity  of  the  healthy  or  comparatively  healthy  organ. 
Without  information  of  this  kind  nephrectomy  cannot  be 
performed. 

Contra-indications. — In  a  hsematogenous  suppurative 
affection  of  the  kidney  associated  with  multiple  foci  else- 
where, operation  is  inadvisable,  particularly  when  the 
causal  condition  cannot  be  treated  (ulcerative  endocarditis)  ; 
bilateral  renal  suppuration  is  not  in  itself  a  contra-indication. 
Other  serious  complicating  affections  also  contra-indicate 
intervention.  As  a  rule  the  demonstration  of  a  severe 
bilateral  pyelitis  secondary  to  bladder  disease  is  a  deterrent 
to    operation.     If   cysto-pyelonephritis    supervenes    in    the 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.    433 

course  of  some  central  nervous  disease  (tabes),  any  surgical 
intervention  will  also  be  entirely  unsatisfactory. 

Prognosis. — Results  of  operation. — Suppurative  renal 
affections  are  often  cured  by  nephrotomy.  In  many  cases 
of  small  multiple  abscesses,  recovery  has  been  obtained  by 
splitting  the  kidney  or  resection  of  the  affected  portion 
(Rovsing).  Even  in  the  ascending  infections,  with  suppu- 
ration of  the  kidney,  operation  often  produces  marked 
amelioration  and  cure. 

Risks  of  operation. — -If  one  kidney  is  removed  and  the 
other  is  defective  in  functional  capacity,  a  fatal  ursemia  is 
to  be  expected.  Patients  who  have  been  much  weakened 
by  long  suppuration  are  very  susceptible  to  the  risks  of 
general  anaesthesia. 

Without  operation.- — A  suppurative  renal  affection  may 
be  the  starting-point  of  a  general  septicaemia.  Chronic 
disease  tends  to  produce  waxy  changes  in  other  organs. 
Sometimes  the  pus  evacuates  itself  through  the  renal  pelvis. 
The  rupture  of  abscesses  is  signalized  by  a  sudden  pyuria 
and  the  subsidence  of  fever,  pain,  and  the  general  symptoms. 

In  two  cases  recently  under  observation,  the  following 
was  the  course  of  events.  Both  were  about  to  be  submitted 
to  operation,  and  the  only  delay  was  the  necessity  for 
completing  the  clinical  examination.  After  the  onset  of 
pyuria,  the  fever,  tenderness,  and  leucocytosis  disappeared. 
In  both  there  was  a  short  recurrence  of  symptoms,  termi- 
nating in  the  same  manner  as  before,  and  then  complete 
recovery  followed.  In  neither  was  the  original  seat  of 
infection  discovered.  Such  a  happy  course  of  events  is  not, 
however,  usual  ;  the  suppurative  focus  usually  extends  to 
the  whole  organ,  and  then  ruptures  through  the  capsule, 
and  may  reach  the  exterior.  A  fistula  thus  established 
continues  to  discharge  and  shows  no  tendency  to  heal,  and 
waxy  disease  or  some  secondary  wound  infection  may  result. 
In  some  cases  the  pus  makes  its  way  into  the  bowel  or  some 
other  organ. 

LITERATURE. 

Senator.  Die  Krankheiten  der  Niere.  Nothnagel's  Handbuch 
d.  spez.  Pathol,  u.  Therap.     2nd   Ed.     Wien,   1903. 

ScHEDE.  Krankheiten  der  Niere.  Handbuch  d.  prakt.  Chir., 
herausgegeben  v.  Bergmann,  Mikulicz,  u.  Bruns.  2nd  Ed. 
Stuttgart,    1903. 

28 


434  INDICATIONS    FOR    OPERATION    IN 

Israel.  Chirurgische  Klinik  der  Nierenkrankheiten.  Berlin, 
1901. 

RovsiNG.  Operation  chronischer  Nephritiden.  Mitteil.  a.  d. 
Grenzgebiete  d.  Med.  u.  Chir.     Bd.  x. 

Jaffe.  Zur  Chirurgie  des  metastatischen  Nierenabscesses. 
Mitteil.  a.  d.  Grenzgebiete  d.  Med.  u.  Chir.     Bd.  ix. 

WiLiNis.  Spaltung  der  Niere  bei  akuter  Pyelonephritis  mit 
miliaren  Abscessen.     Miinch.  med.  Wochens.,  1902,  No.   12. 

Lennander.  Spaltung  der  Niere  bei  akuter  Pyelonephritis  mit 
miliaren    Abscessen.     Nord.    Med.    Arch.      1901. 

Albarran.  Maladies  Chirurgicales  du  Rein.  Traite  de  Chirurgie. 
Paris,  1898. 

GuYON.  Die  Krankheiten  der  Harnwege.  Teil  ii.  Translated 
by    O.   Krauss  u.   O.   Zuckerkandl.     Wien.      1899. 

KusTER.  Die  Chirurgischen  Krankheiten  der  Nieren.  Deut. 
Chir.     Stuttgart.      1897. 

Herszky.  Nierenabscess  und  Perinephritis.  Kritisches  Sammel- 
referat.     Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.      1903. 


PERINEPHRITIS. 

Etiology. — Perinephritis  is  sometimes  secondary  to 
lumbar  injuries  ;  it  is  often  due  to  extension  from  neighbour- 
ing structures,  and  in  this  way  it  may  follow  renal  abscess, 
pyelitis,  pyelonephritis,  pelvic  abscess,  vertebral  disease, 
and  abscesses  of  the  liver  and  spleen.  It  may  occur  as  a 
metastatic  process  in  pyaemia. 

It  is  especially  common  about  middle  life,  and  in  men. 

Pathological  Anatomy. — The  condition  is  usually  uni- 
lateral. Israel  distinguishes  three  chief  forms  :  (i)  The 
fibrosclerotic  ;  (2)  The  lipomatous  ;  (3)  The  phlegmonous. 
The  fibrosclerotic  form  transforms  the  fatty  capsule  into  a 
dense  fibrous  mass.  In  the  lipomatous  there  is  sometimes 
a  very  pronounced  overgrowth  of  fat  surrounding  the  whole 
kidney.  The  phlegmonous  type  originates  either  in  the 
fatty  capsule  itself,  or  by  extension  from  a  neighbouring 
suppurative  focus,  or  as  a  metastatic  infection. 

In  many  of  the  cases  where  the  perinephritis  apparently 
originates  in  the  fatty  capsule,  the  real  starting-point  is  a 
small  abscess  of  the  kidney  ;  of  43  cases  operated  on  by. 
Israel,  34  originated  in  this  way. 

The  phlegmonous  inflammation  may  start  as  a  sub- 
capsular process,  or  in  the  fatty  capsule,  or  in  the  retro- 
peritoneal   fatty    tissue.     Most    frequently    the    purulent 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.    435 

collection  forms  behind  the  kidney  ;  it  tends  to  spread 
upwards  through  the  diaphragm  to  the  subpleural  tissue, 
and  may  rupture  into  a  bronchus.  In  other  cases  the 
pus  makes  its  way  downwards  to  the  thigh,  or  becomes 
superficial  in  the  lumbar  region,  or  may  discharge  into 
the  bowel. 

Clinical  Course. — The  commencement  of  the  affection 
is  often  associated  with  general  symptoms  only — -fever, 
exhaustion,  and  rigors  ;  local  symptoms  either  succeed  these 
or  may  appear  at  the  same  time.  Pain  is  localized  in  the 
loin,  and  is  exaggerated  by  deep  inspiration,  by  pressure, 
and  by  active  movement  ;  it  may  be  absent  during  the 
earliest  stages.  I  have  found  hyperaesthesia  in  several  cases 
over  the  area  supplied  by  the  ileohypogastric  nerve,  and 
sometimes  there  is  distinct  cutaneous  hyperaesthesia  in  the 
loin.  Meteorism  is  often  present,  and  the  respiratory 
movements  are  usually  shallow. 

Sometimes  the  onset  is  characterized  by  vomiting  and 
urinary  tenesmus,  and  renal  elements  are  found  in  the  urine, 
which  owe  their  presence  to  the  nephritis,  to  which  the 
perinephritis  is  secondary. 

Sometimes  in  the  early  stages  the  hip  on  the  affected 
side  is  kept  flexed,  but  it  is  only  extension  which  is  limited, 
the  other  movements  remaining  free.  Pain  may  radiate 
down  the  sciatic  nerve,  and  the  lumbar  spine  may  be  kept 
rigid.  The  condition  may  be  present  for  some  considerable 
time  before  an  actual  lumbar  swelling  makes  its  appearance, 
but  sooner  or  later  this  develops.  A  local  oedema  of  the 
skin  in  the  loin  is  a  diagnostic  point  of  much  value.  The 
swelling,  although  involving  the  kidney  region,  has  not  the 
well-defined  shape  of  an  enlarged  kidney,  its  margin  being 
irregular,  it  does  not  move  with  respiration,  and  it  gradually 
increases  in  size.  It  may  be  possible  to  make  out  fluctuation. 
If  left  alone  it  comes  to  the  surface  and  ruptures,  or  it  may 
perforate  into  the  bowel,  the  bladder,  or  some  other  organ. 
In  other  cases  there  is  a  tendency  towards  the  diaphragm 
from  the  early  stages,  and  the  abscess  becomes  subphrenic, 
and  may  further  make  its  way  into  the  thorax  and  perforate 
into  the  pleura  or  the  lung.  In  such  cases  a  dry  pleurisy 
often  develops  early.  A  radiograph  may  show  the 
diaphragm  pushed  up  on  one  side  and  comparatively 
immobile. 


436  INDICATIONS    FOR    OPERATION    IN 

One  of  my  cases  was  that  of  a  young  man  who  developed 
a  dry  pleurisy  at  the  base  of  the  right  lung,  with  fever  and 
rigors.  The  fever  remained  high  in  spite  of  the  absence  of 
exudation  and  any  recognizable  lung  affection.  Dull  pains 
in  the  loin  early  gave  rise  to  a  suspicion  of  perinephritis,  and 
a  resistance  developed  here  with  an  overlying  inflammatory 
oedema.  A  large  retrorenal  abscess  was  opened,  extending 
upwards  to  the  diaphragm,  and  the  man  recovered.  The 
pleurisy  soon  subsided  after  the  operation. 

Diagnosis. — If  the  cardinal  symptoms — fever,  pain,  and 
swelling — are  all  present,  the  diagnosis  is  clear.  The  most 
instructive  and  important  sign  is  the  swelling,  particularly 
if  it  extends  along  the  course  of  the  psoas,  which  a  renal 
tumour  does  not.  Extension  and  protrusion  towards  the 
loin,  without  any  large  palpable  tumour,  is  characteristic  of 
perinephritis,  but  not  of  renal  tumour.  Marked  tenderness 
on  pressure  in  the  loin  is  characteristic  of  perinephritis  ;  in 
inflammatory  swelling  of  the  kidney  the  tenderness  is  more 
in  front.  Normal  urine  points  to  the  absence  of  any  other 
complicating  renal  disease.  Against  "  lumbago  "  is  the 
pyrexia  and  the  unilateral  nature  of  the  complaint. 

In  tubercular  abscess  some  tubercular  bone  lesion  above, 
of  vertebrse  or  rib,  will  be  discoverable.  An  appendix 
abscess  or  an  abscess  originating  in  the  genital  organs  has 
been  mistaken  for  perinephritis.  Extension  towards  the 
loin  is  not  frequent  in  these  conditions.  In  perinephritis 
there  is  no  rigidity  of  the  abdominal  wall,  and  no  resistance 
in  the  crecal  region. 

INDICATIONS  FOR  OPERATION. 

If  there  is  only  a  definite  suspicion  of  perinephritis, 
operation  is  necessary.  Early  diagnosis  is  of  the  greatest 
importance  in  order  that  early  relief  may  be  given.  If  fever 
is  present,  if  there  is  a  resistance  in  the  loin  and  tenderness 
on  pressure,  and  leucocytosis,  the  signs  are  sufficiently 
marked  to  warrant  incision.  Operation  will  be  justified 
even  when  there  is  no  definite  resistance  if  there  is  an 
inflammatory  oedema  of  the  skin.  If  an  exploratory 
puncture  reveals  pus,  incision  is  of  course  called  for. 

There  cannot  be  said  to  be  any  contra-indication  unless 
there  is  some  complication  which  makes  the  case  hopeless. 

Prognosis. — Risks   of   operation. — Since    only  a    simple 


DISEASES  OF  THE  KIDNEY  AND  RENAL  PELVIS.    437 

incision  is  usually  necessary,  the  operative  risk  is  small. 
Sometimes  the  kidney  is  completely  disorganized  and  has 
to  be  removed,  and  the  risk  is  thereby  increased.  Suppu- 
ration of  an  undamaged  kidney  is  only  to  be  feared  when 
some  operative  measure  encroaching  on  the  kidney  (removal 
of  a  stone,  for  example)  has  to  be  associated  with  the 
opening  of  the   abscess. 

Results  of  operation. — Complete  relief  usually  follows  the 
evacuation  of  the  pus,  and  the  patient  usually  makes  a 
rapid  recovery. 

Without  operation. — It  has  already  been  remarked  that 
the  pus  often  makes  its  way  into  the  thorax  ;  according 
to  Fischer,  in  20  per  cent  of  the  unoperated  cases  the  lung 
becomes  involved ;  the  pus  may  also  come  to  the  surface, 
or  rupture  into  a  hollow  abdominal  organ.  Such  extension 
to  other  organs  may  give  rise  to  dangerous  complications. 
Spontaneous  recovery  does  sometimes  occur  in  this  way, 
but  it  will  of  course  never  be  deliberately  counted  on.  Even 
if  the  pus  does  not  penetrate  in  this  way,  all  the  symptoms 
caused  by  retention  of  such  collections  in  the  body  will  tend 
to  supervene,  i.e.,  pyaemia  and  septicaemia,  and  a  remediable 
may  become  an  irremediable  affection. 

LITERATURE. 

Israel.  Chirurgische  Klinik  der  Nierenkrankheiten.  Berlin. 
1901. 

Senator.  Die  Erkrankungen  der  Nieren.  2nd  Ed.  Wien. 
1902. 

ScHEDE.  Krankheiten  der  Niere.  Handbuch  d.  prakt.  Chir, 
herausgegeben  v.  Bergmann,  Mikulicz,  u.  Bruns.  2nd  Ed. 
Stuttgart.      1903. 

Herszky.  Nierenabscess  und  Perinephritis.  Zusammenfassendes 
Referat.    Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.     No.  i,  1903. 

Albarran.  Maladies  Chirurgicales  du  Rein.  Traite  de  Chir., 
Paris.      1898. 

Sachs.  Der  subphrenische  Abscess  im  Anschlusse  an  peri- 
nephritische  Eiterung.     Arch.   f.   klin.   Chir.     Bd.   1. 

Maydl.     Der  subphrenische  Abscess.     Wien  :    Safar. 

Prior.  Peri-  und  Paranephritis.  Handbuch  d.  Krankheiten  d. 
Harnund  Sexualorgane,  herausgegeben  v.  Oberlander  u.  Zenker. 


CHAPTER     XXIV. 
Diseases    of    the    Bladder. 


441 


Chapter  XXIV. 
DISEASES  OF  THE  BLADDER. 

CYSTITIS. 

Etiology. — Cystitis  is  always  caused  by  micro-organismal 
infection,  which  may  be  conveyed  either  by  the  urethra  or 
from  the  kidney.  In  the  latter  case  the  process  may  be 
either  directly  descending,  or  the  bladder  may  be  infected 
by  microbe-containing  urine  from  an  unaltered  kidney. 
Finally  the  vesical  mucous  membrane  may  be  infected 
through  the  blood  stream,  or  by  extension  from  some 
adjacent  focus. 

Associated  causes  are  calculi,  growths,  and  foreign  bodies. 
Diseases  of  the  central  nervous  system  and  of  the  prostate, 
pregnancy  and  labour,  and  senile  changes  are  all  pre- 
disposing causes. 

Pathological  Anatomy. — Superficial,  parenchymatous, 
and  ulcerative  forms  are  distinguished,  and  the  condition 
may  be  circumscribed  or  diffuse.  In  chronic  cystitis  the 
mucous  membrane  and  muscular  coats  are  hypertrophied, 
the  wall  is  thus  thickened,  and  prominent  trabeculse  are 
formed. 

Clinical  Course. — The  characteristic  symptoms  are, 
intense  and  frequent  desire  to  pass  water,  and  pain  during 
the  act.  The  bladder  is  sensitive,  for  example,  on 
catheterization,  and  tender  to  pressure.  Cystoscopic  exami- 
nation shows  injection  of  the  mucous  membrane,  which 
bleeds  readily,  and  in  some  cases  ulceration.  The  urine 
contains  pus,  sometimes  blood,  the  reaction  is  often  acid, 
but  if  there  is  retention  of  urine  it  is  frequently  alkaline  and 
ammoniacal.  The  organisms  most  frequently  found  are 
staphylococci,  streptococci,  B.  proteus,  B.  coli,  and  gonococci. 
An  acute  attack  may  be  followed  by  chronic  disease  persisting 
for  several  years,  with  acute  exacerbations.     In  other  cases 


442  INDICATIONS    FOR    OPERATION    IN 

the  process  rapidly  extends  to  the  upper  urinary  passages. 
If  the  inflammatory  process  spreads  to  the  deeper  layers  of 
the  wall,  the  bladder  may  become  shrunken,  and  the  patient 
in  this  condition  will  have  an  almost  constant  desire  to  pass 
water.  In  some  cases  a  cystitis  is  followed  by  a  perivesical 
cellulitis  which  may  extend  to  the  peritoneum,  the  perineum, 
or  the  perirectal  connective  tissue. 

Diagnosis. — Painful  micturition,  tenesmus,  and  purulent 
urine  are  present  in  many  renal  affections  (tuberculosis, 
infected  calculous  disease,  etc.),  as  well  as  in  cystitis,  and 
some  of  the  symptoms  are  present  in  inflammatory  affections 
near  the  bladder.  If  the  vesical  symptoms  undergo  a  sudden 
unexplained  change,  while  the  pyuria  remains  constant, 
some  extravesical  inflammation  must  be  suspected.  Careful 
examination  of  the  kidneys  and  the  urine,  cystoscopy,  and 
separation  of  the  urine  will  show  whether  the  symptoms  are 
due  to  renal  disease.  Tenderness  on  catheterization,  on 
pressure  from  the  vagina  or  the  rectum,  point  to  a  vesical 
rather  than  a  renal  affection.  The  two-glass  test  differ- 
entiates a  vesical  from  a  urethral  suppuration. 

INDICATIONS  FOR  OPERATION. 

If  strangury  and  painful  contractions  of  the  bladder 
persist  in  spite  of  persevering  and  energetic  local  treatment, 
and  in  spite  of  drainage  by  catheter  and  medicinal  treat- 
ment, the  organ  must  be  placed  at  rest  by  incision  and 
drainage.  The  fistula  will  be  maintained  only  as  a  tem- 
porary measure,  and  will  be  allowed  to  heal  when  the 
cystitis  begins  to  improve.  If  the  changes  in  the  mucous 
membrane  show  no  improvement  in  spite  of  persistent  local 
treatment,  and  the  cystoscope  shows  fungous  granulations 
or  ulceration,  these  must  be  dealt  with  by  the  sharp  spoon 
and  by  the  cautery.  The  ulcerative  and  membranous  form 
of  the  disease  must  be  treated  by  cystotomy  and  local 
treatment  when  there  is  intense  pain  and  haemorrhage,  and 
the  membranous  deposit  does  not  clear  up. 

Contra-indications. — No  operation  should  be  done  until  a 
proper  attempt  has  been  made  to  cure  the  condition  by 
lavage,  internal  medication,  or  drainage  by  catheter. 
Disease  of  the  central  nervous  system  is  in  general  a  contra- 
indication to  operation  ;  if  improvement  takes  place,  which 
is  exceptional,  recurrence  soon  follows. 


DISEASES    OF    THE    BLADDER.  443 

Prognosis. — Results  of  operation. — In  many  cases,  after 
opening  and  draining  the  bladder,  the  pain  and  tenesmus 
improve  greatly,  and  the  urine  also  becomes  clearer. 
Cauterization  and  scraping  are  procedures  from  which  good 
results  are  often  obtained. 

LITERATURE. 

ZucKERKANDL.  Die  lokalcn  Erkrankungen  der  Harnblase. 
Wien.  1899.  Nothnagel's  Handbuch  d.  spez. '  Pathol,  u.  Therap. 
Bd.  xix. 

GuYON.  Klinik  der  Krankheiten  der  Harnblase.  Translated 
by  Mendelsohn.      1893. 

NiTZE  und  SoNNENBURG.  Verlctzungen  und  Erkrankungen  der 
Harnblase.  Handbuch  d.  prakt.  Chir.,  herausgegeben  v.  Bruns, 
Mikulicz,  u.  Bergmann.     2nd  Ed.,  Bd.  iii.     Stuttgart.      1903. 


NOCTURNAL    ENURESIS. 

.  There  are  two  chief  types  of  this  affection  :  (i)  The 
symptomatic  type,  due  to  some  pathological  lesion  of  a  local 
nature,  or  of  the  spinal  cord  or  brain  ;  (2)  Essential  enuresis 
without  changes  in  the  urogenital  apparatus,  the  central 
nervous  system,  or  the  urine.  The  latter  type  alone  will 
be  here  considered  ;  it  is  of  the  nature  of  a  neurosis.  It  is 
sometimes  due  to  psychic  abnormalities  ;  in  other  cases  it 
is  ascribable  to  diseases  of  nutrition,  scrofula,  anaemia,  and 
the  uratic  diathesis.  In  many  cases  some  local  affection 
appears  to  be  the  cause  ;  thus  it  occurs  in  vesical  calculus, 
stricture  of  the  urethra,  phimosis,  atony  of  the  sphincter. 
Occasionally  there  is  an  hereditary  predisposition.  It  is 
more  common  in  boys  than  girls,  and  usually  disappears  in 
all  cases  before  the  age  of  fourteen. 

Symptoms. — The  enuresis  occurs  usually  in  deep  sleep 
after  the  child  has  been  some  hours  in  bed,  and  the  urine  is 
usually  passed  in  considerable  quantities.  The  child  does 
not  necessarily  wake.  Not  uncommonly  there  is  some 
spasmodic  contraction  of  the  leg  muscles,  especially  the 
adductors.  Faecal  incontinence  is  unusual.  Other  neuroses, 
hysterical  and  neurasthenic  symptoms,  are  often  present. 

INDICATIONS  FOR  OPERATION. 

If  all  the  recommended  general  and  local  methods 
of  treatment  prove  ineffectual,  if  the  enuresis  is  persistent 


444  INDICATIONS    FOR    OPERATION    IN 

and  frequent  and  is  causing  eczema,  and  if  the  child  is 
some  distance  removed  from  the  age  when  spontaneous 
cure  is  usual,  intervention  is  justifiable.  This  will  take 
the  form  of  an  epidural  injection  of  cocaine,  or  saline 
solution  (^  per  cent),  and  will  be  made  into  the  sacral 
canal.  Cathelin  has  carried  out  this  treatment  on  more 
than  1000  occasions,  and  Kappsammer  on  more  than  300, 
and  neither  has  to  record  any  unfavourable  results. 
Kappsammer  records  25  cases  which  were  followed  up,  all 
being  cured  of  the  affection  ;  Cathelin  and  Albarran  also 
report  recoveries  and  improvement. 

When  left  alone  the  affection  is  very  persistent.  It  may 
recur  even  after  some  months  of  freedom. 

LITERATURE. 

V.  Frankl-Hochwart  und  Zuckerkandl.  Die  nervosen  Er- 
krankungen  der  Blase.  Nothnagel's  Handbiich  d.  spez.  Path.  u. 
Therap.     Bd.  xix.     Wien.      1898. 

Landau.  Enuresis  Nocturna.  Kritisches  Sammelreferat.  Cen- 
tralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  No.  11,  1903. 

G.  Kappsammer.  Ueber  Enuresis  und  ihre  Behandlung  mittels 
epiduraler  Injektionen.  Wiener  klin  Wochens.,  No.  29,  30, 
1903. 

Albarran  et  Cathelin.  Traitement  des  Incontinences  d' Urine 
par  les  Injections  Epidurales.  Annales  des  Maladies  des  Voies 
Urinaires.      1901. 

Cathelin.     Les  Injections  Epidurales.     Paris,  1903. 


TUBERCULOSIS  OF  THE  BLADDER. 

Etiology. — Vesical  tuberculosis  is  usually  secondary 
either  to  renal  tuberculosis,  or,  in  the  male,  to  tuberculosis 
of  the  genital  organs.  Occasionally,  however,  it  is  found 
as  the  sole  focus  of  the  disease  clinically  discoverable. 
Gonorrhceal  cystitis  appears  to  predispose  to  the  tubercular 
disease.  It  is  much  more  common  in  males  than  in  females, 
and  among  the  poor  than  the  well-to-do  class. 

Pathological  Anatomy. — Circumscribed  foci  are  often 
present  ;  these  are  most  common  about  the  ureteral  orifices 
when  the  disease  has  descended  from  the  kidney,  and  about 
the  neck  of  the  bladder  when  it  has  had  its  origin  in  the  male 
genital  organs.  In  other  cases  the  whole  mucous  membrane 
is  beset  with  nodules.     When  these  caseate  and  break  down. 


DISEASES    OF    THE    BLADDER.  445 

superficial  ulcers  of  considerable  size  develop,  and  on  these 
ulcers  incrustations  are  often  formed.  When  the  ulceration 
is  extensive,  the  whole  inner  lining  of  the  bladder  is  red, 
swollen,  and  hasmorrhagic.  In  some  cases  a  purulent  peri- 
cystitis occurs  in  consequence  of  the  deep  extension  of  the 
ulceration. 

Clinical  Course. — The  first  symptoms  of  bladder 
tubercle  are  increased  frequency  of  micturition,  intense 
desire  to  empty  the  bladder,  and  pain  during  the  act. 
During  the  intervals  the  pain  persists  in  the  penis  and 
the  perineum.  As  the  process  of  ulceration  develops, 
spontaneous  haemorrhages  occur  ;  these  are  frequent,  but 
rarely  profuse,  and  are  often  among  the  early  signs  of  the 
disease.  Occasionally  incontinence  of  urine  sets  in,  and  in 
some  cases  this  is  complete.  Severe  general  symptoms — 
hectic  fever  and  profuse  night  sweats — are  common  in  the 
more  advanced  stages  of  the  disease. 

Usually  a  tubercular  focus  in  some  other  organ  can  be 
discovered. 

In  the  early  stages  the  urine  is  acid,  clear,  or  slightly 
turbid  from  pus.  Later  the  amount  of  pus  increases  and 
blood  is  also  present,  but  blood  may  also  occur  at  an  early 
stage.  When  the  pyuria  is  well  marked,  the  reaction  is 
often  alkaline.  Palpation  often  demonstrates  tenderness 
and  contraction  of  the  bladder  wall. 

Diagnosis. — The  spontaneous  occurrence  of  hasmaturia 
in  young  individuals  who  have  never  had  gonorrhoea,  and 
have  never  had  an  instrument  in  the  bladder,  is  almost  a 
pathognomonic  sign  of  tuberculosis  (Zuckerkandl),  par- 
ticularly if  renal  calculus  can  be  excluded.  The  onset  of 
cystitis,  without  apparent  cause,  in  an  individual  with  a 
tuberculous  family  history,  or  with  tubercular  lesions  else- 
where, suggests  vesical  tuberculosis,  and  the  discovery  of 
tubercle  bacilli  in  the  urine  and  cystoscopic  examination  will 
settle  the  diagnosis.  The  presence  of  nodular  masses  in 
the  prostate,  seminal  vesicles,  vasa  deferentia,  or  epididymes 
will  point  to  tuberculosis.  New  growths  will  be  excluded 
by  the  slightness  and  at  the  same  time  the  persistence  of 
the  hsematuria,  and  by  the  positive  discovery  of  tubercle 
bacilli.  Chronic  cystitis  has  usually  some  definitely  known 
cause,  is  improved  by  treatment,  and  does  not  tend  to 
produce  hsematuria. 


446  INDICATIONS    FOR    OPERATION. 

INDICATIONS  FOR  OPERATION. 

There  is  no  general  rule  for  surgical  interference,  the 
advisability  of  operation  depending  frequently  on  the 
condition  of  the  associated  organs.  If  the  bladder  disease 
is  secondary  to  a  unilateral  renal  tuberculosis,  the  indication 
is  to  attack  the  disease  in  the  kidney  ;  the  elimination  of 
the  renal  disease  is  usually  followed  by  healing  of  the  bladder 
lesions.  If  the  bladder  disease  is  associated  with  genital 
lesions,  the  latter  should  be  operated  on  first  and  the  bladder 
later.  If  the  bladder  disease  is  clinically  the  primary  lesion, 
if  local  therapeutics  fail,  and  the  pain  and  distress  are  great, 
operation  is  indicated.  This  will  consist  in  eradication  of 
the  disease  foci,  with  or  without  cystotomy,  of  excision  in 
the  case  of  solitary  ulcers,  or  finally  in  resting  the  bladder 
by  the  establishment  of  a  fistula. 

Contra-indications. — If  there  is  extensive  genital  tuber- 
culosis, or  bilateral  renal  tuberculosis,  or  advanced 
tubercular  lesions  elsewhere,  operation  on  the  bladder  is 
useless.  Cases  in  which  the  disease  is  florid  and  making 
rapid  progress  are  unsuitable  for  operation. 

Prognosis. — Results  of  operation. — Operation  often  pro- 
duces a  rapid  improvement  in  the  subjective  symptoms. 
After  opening  the  bladder,  the  pain,  distressing  tenesmus, 
and  haemorrhage  may  all  improve.  In  some  cases  cure  has 
been  obtained  by  direct  eradication  of  the  disease.  In 
many  cases  there  occurs,  however,  a  local  return,  and  in 
others  other  parts  of  the  urogenital  apparatus  are  attacked 
by  the  disease.  If  the  tubercular  products  are  not  dealt 
with  by  operation,  the  extension  of  the  disease  tends  to  be 
the  more  rapid,  and  dangerous  complications  supervene 
the  earlier. 

LITERATURE. 

ZucKERKANDL.  Die  lokalen  Krankheiten  der  Harnblase.  Noth- 
nagel's  Handbuch  d.  spez.  Pathol,  u.  Therap.  Bd.  ix,  Teil  2. 
Wien,    1899. 

KuMMELL.  Die  Krankheiten  der  Blase.  Handbuch  d.  prakt. 
Med.,  herausgegeben  v.  Ebstein  u.  Schwalbe.  Bd.  iii,  Teil  i. 
Stuttgart,   1900. 

Fritsch.  Die  Krankheiten  der  weiblichen  Blase.  Veit's  Hand- 
buch d.  Gynakologie.     Wiesbaden,   1897. 

Stoeckel.  Zur  Diagnose  und  Therapie  der  Blasen-Nierentuber- 
kulose  bei  der  Frau.  Beit.  z.  Klin,  der  Tuberkulose.  Bd.  i.  H.  2. 
A.  Stuber's  Verlag.     Wurzburg,  1903. 


CHAPTER     XXV. 

Diseases    of    the    Joints    and    Bones. 


449 


Chapter    XXV. 
DISEASES  OF   THE f  JOINTS  AND  BONES. 

THE    NERYOUS    ARTHROPATHIES. 

Etiology. — These  affections  occur  in  patients  suffering 
from  organic  disease  of  the  nervous  system,  especiahy  tabes 
and  syringomyeha.  Trauma  appears  to  play  a  considerable 
part  in  their  causation. 

Pathological  Anatomy. — -Investigation  of  specimens 
lias  shown  that  the  changes  in  the  joints  are  of  similar 
character  in  the  various  nervous  diseases  in  which  these 
affections  occur.  From  the  appearances  of  a  specimen 
alone  it  would  be  impossible  to  say  whether  the  patient 
had  suffered  from  tabes  or  syringomyelia.  These  joint 
■changes  assume  two  forms,  the  atrophic  arid  the  hyper- 
trophic. In  the  former,  the  articular  ends  of  the  bones  are 
gradually  worn  away,  and  even  a  considerable  portion  of 
the  diaphysis  may  be  absorbed  if  the  patient  continues  to  use 
Iiis  limbs  ;  in  a  tabetic  patient  under  my  care,  a  fourth  of 
the  length  of  the  femur  disappeared  in  this  way.  The 
absorption  of  articular  cartilage  and  bone,  the  exudation  in 
the  joint,  and  the  relaxation  of  ligaments  often  permits 
very  considerable  dislocation  to  take  place.  In  the  hyper- 
trophic form  the  joints  are  enlarged  ;  the  articular  cartilage 
disappears,  and  its  place  is  taken  by  exuberant  newly- formed 
connective  .  tissue.  The  synovial  membrane  is  often 
distended  and  shows  numerous  ragged  outgrowths,  and 
there  are  often  cartilaginous  or  osseous  loose  bodies  in  the 
joint.  The  joint  capsule  is  much  thickened,  and  there  are 
often  exostoses,  and  sometimes  ossified  muscles,  around  it. 
Sometimes  the  capsule  gives  way  at  one  or  more  points. 
Occasionally  the  atrophic  and  hypertrophic  forms  are 
•combined. 

29 


450  INDICATIONS    FOR    OPERATION    IN 

Clinical  Course. — The  affection  often  has  a  sudden 
onset,  with  enormous  effusion  into  the  joint,  and  sometimes 
marked  swelhng  of  the  whole  extremity.  There  is  no  fever. 
The  effusion  may  remain  stationary  or  be  absorbed,  to 
reappear  after  a  time  either  spontaneously  or  following  some 
slight  trauma.  After  each  effusion  the  joint  changes  become 
more  advanced,  and,  as  already  remarked,  they  may  be  either 
atrophic  or  hypertrophic  in  character.  In  the  former  case 
the  articular  surfaces  separate  and  the  joint  becomes 
flail ;  in  the  latter  the  joint  becomes  enormously  enlarged 
and  deformed.  The  thickening  and  distension  of  the  capsule, 
the  building  up  of  new  connective  tissue,  the  formation  of 
exostoses  and  intra-articular  masses  may  reach  extra- 
ordinary proportions.  Spontaneous  fracture  of  the  bones, 
near  the  joint  frequently  occurs.  There  is  absence  of  pain 
throughout. 

In  tabes  the  joints  of  the  lower  limb  are  those  usually 
affected  :  the  knee  and  the  hip  ;  in  syringomyelia,  on  the 
other  hand,  it  is  the  joints  of  the  arm  that  are  usually 
involved  :  the  shoulder,  the  elbow,  and  wrist.  In  tabes  the 
affection  is  often  bilateral  ;    in  syringomyelia,  rarely  so. 

These  joint  changes  may  occur  early  in  the  course  of  the 
disease  to  which  they. are  due.  Serious  complications  may 
supervene  ;  a  local  necrotic  process  may  set  in,  involve  the 
bones,  and  extend  to  the  joint.  A  suppurative  arthritis 
is  thus  set  up.  This  may  also  occur  as  a  metastatic  process. 
It  is  usually  attended  by  high  fever  and  rigors.  Sometimes 
a  fistula  forms  communicating  with  the  joint  and  discharging 
a  serous  fluid.  The  patients,  as  a  rule,  tolerate  these  septic 
processes  surprisingly  well. 

With  regard  to  differential  diagnosis,  arthritis  deformans 
is  the  only  condition  with  which  there  might  be  some 
confusion ;  the  painful  nature  of  this  process  is  sufficient  tO' 
distinguish  it. 

INDICATIONS  FOR  OPERATION. 

Since  these  arthropathic  lesions  occur  in  the  course  of 
progressive  nervous  maladies,  and  often  spontaneously 
retrocede,  most  surgeons  have  with  good  reason  advised 
against  operation  when  they  run  an  uncomplicated  course, 
and  have  confined  treatment  to  the  use  of  some  orthopaedic 
apparatus.      Sometimes,  however,  even  if  no  complication 


DISEASES    OF    THE    JOINTS    AND    BONES.        45: 

is  present,  operation  is  advisable  ;  if  the  effusion  becomes 
excessive  and  persists  for  a  long  time,  and  if  the  sensation 
of  distension  is  very  troublesome,  puncture  followed  by 
compression  is  indicated.  The  more  extensive  operations 
— resection  and  arthrodesis — are  not  called  for  on  account 
of  pain,  but  may  be  justified  by  other  circumstances.  If 
the  limb  has  been  rendered  flail,  and  the  patient  is  quite 
incapacitated  from  work  thereby,  operation  is  to  be  recom- 
mended, and  when  it  is  the  upper  limb  that  is  affected, 
resection  will  be  chosen.  A  further  indication  is  provided 
when  the  lower  limbs  are  affected,  and  the  patient  is  unable 
to  walk  without  help,  or  when  his  helplessness  confines  him 
to  bed.  If  the  articulation  suppurates,  operation  must 
of  course  be  done,  also  if  the  fluid  makes  its  way  to  the 
surface  and  creates  a  fistula,  or  if  there  is  bony  necrosis 
and  the  sequestrum  does  not  separate  spontaneously. 
In  all  such  cases  the  joint  must  be  opened  and  resected  or 
the  limb  amputated. 

Contra-indications. — If  the  affection  is  present  only  in  a 
moderately  severe  form,  if  it  is  recent  and  uncomplicated, 
and  has  not  made  the  limb  useless,  no  operation  should  be 
done.  Severe  complications  and  a  bad  general  condition 
(waxy  disease)  are  also  contra-indications.  One  would 
hesitate  also  if  the  lesions  were  multiple  and  of  a  severe  type. 

Prognosis. — Results  and  risks  of  operation. — In  uncom- 
plicated cases  the  functional  usefulness  of  a  joint  may  be 
improved.  I  have  seen  this  after  resection  of  the  shoulder 
in  several  cases  of  syringomyelitic  arthropathy,  and  also 
in  cases  of  tabes  with  advanced  arthropathic  deformity  of 
the  knee.  The  joint  condition  is  not,  however,  curable  by 
operation.  If  the  'indications  already  given  are  followed, 
no  serious  risk  is  attached  to  operation.  If  the  joint 
suppurates  or  threatens  to  suppurate,  operation  may  be 
directly  life-saving. 

When  no  operation  is  undertaken  and  the  affection  is 
complicated,  death  may  take  place  from  septicaemia  or 
pyaemia,  or,  when  a  more  chronic  course  is  followed,  from 
waxy  disease  of  the  internal  organs. 

LITERATURE. 

SoKOLOFF.  Erkrankheiten  der  Gelenke  bei  Syringomyelie. 
Deut.  Zeits.  f.  Chir.     Bd.  xxxiv.  u.  ci. 


452  INDICATIONS    FOR    OPERATION    IN 

H.   ScHLESiNGER.       Die   Syringomyelie.      2nd  Ed.      Wien,    1902. 

Gnesda.  Lehre  von  spinalen  Oedeni.  Alitteil.  a.  d.  Grenzgebiete 
d.    Med.  u.  Chir.     Bd.  iv. 

BuDiNGER.     Ueber   Tabische    Gelenkerkrankungen.      1896. 

Chipault.  Las  Arthropathies  Trophiques.  Nouv.  Iconogr.  de 
la  Salpetriere.      1894. 

KLEMJii.  Ueber  Arthritis  Deformans  bei  Tabes  u.  Syringomyelie. 
Deut.  Zeits.  f.  Chir.     Bd.  xxxix. 


ARTHRITIS    DEFORMANS. 

Etiology. — Age,  trauma,  heredity,  and  anomalies  of 
nutrition,  all  appear  to  exercise  some  causative  influence. 

Pathological  Anatomy. — The  disease  gives  rise  on  the 
one  hand  to  erosion  of  the  cartilages  of  the  joint  and 
eburnation  of  the  bones,  and  on  the  other  to  osseous  and 
cartilaginous  proliferation,  thickening  of  the  capsule,  and, 
at  least  temporarily,  to  considerable  effusion.  Following 
relaxation  of  the  ligaments,  luxation  or  subluxation  is 
frequent,  and  is  encouraged  by  the  changes  in  contour 
which  the  joint  undergoes.  Not  uncommonly  hyperplastic 
fringes  are  present  in  the  articulations,  and  these  may  become 
free  and  form  loose  bodies.  The  disease  may  be  confined 
to  one  joint  or  be  present  in  several. 

Symptoms. — Pain  on  movement  is  present  from  the 
beginning,  and  increases.  Movement  gives  rise  to  a  grating 
sensation  in  the  joint,  and  the  functions  of  the  latter  are 
early  interfered  with.  As  the  disease  progresses  the  joint 
becomes  swollen ;  sometimes  it  becomes  softer,  sometimes 
firmer  to  palpation.  The  changes  can  be  demonstrated 
by  radiograph  at  a  relatively  early  period.  The  swelling 
increases,  movement  becomes  more  and  more  restricted, 
the  joint  surfaces  correspond  less  accurately,  and  there  is 
often  considerable  effusion.  The  skin  over  the  joint  becomes 
smooth  and  shiny  ;  the  bones  remain  normal  in  the  neigh- 
bourhood of  the  joint. 

Diagnosis. — This  is  based  on  the  clinical  characters. 
Nervous  arthropathy  is  distinguished  by  its  painlessness. 
In  chronic  rheumatism  there  is  no  deviation  of  the  joint 
surfaces.  Gonorrheal  rheumatism  produces  fixation  of  the 
joint  from  an  early  stage.  Tuberculosis  is  distinguished  by 
the   rounded  and  doughy  character  of  the  joint  swelling. 


DISEASES    OF    THE    JOINTS    AND    BONES.        453 
INDICATIONS   FOR   OPERATION. 

Operation  is  not  often  called  for.  It  may  take  the  form 
of  the  injection  of  some  irritating  fluid  into  the  joint,  or 
the  removal  of  fringes  and  loose  bodies,  or  resection. 
Resection  is  only  practised  when  the  disease  is  mono- 
articular (it  is  usually  mono-articular  when  of  traumatic 
origin)  ;  it  is  indicated  when  the  pain  is  intolerable,  when 
considerable  deformity  has  taken  place,  and  when  the  patient 
is  becoming  unfitted  for  work,  and  when  he  is  still  com- 
paratively young. 

Loose  bodies  and  fringes  should  be  removed  when  they  are 
causing  marked  disability.  When  the  effusion  is  large  and 
persistent  the  joint  should  be  punctured  and  washed  out. 

Contra-indications. — No  operation  should  be  done  when 
the  patient  is  old,  when  the  process  affects  several  joints, 
or  when  serious  complications  (e.g.,  diabetes)  are  present. 
Puncture  should  not  be  performed  in  the  case  of  a  recent 
effusion  ;    this  is  frequently  absorbed  spontaneously. 

Prognosis. — Results  of  operation. — Pain  is  almost  always 
relieved  by  operation,  function  is  also  frequently  improved, 
but  not  often  completely  restored.  Injection  and  washing 
out  of  the  joint  often  has  a  good  influence  on  the  disease, 
and  the  exsection  of  fringes  and  loose  bodies  often  removes 
disability. 

The  dangers  of  operation  are  slight  when  the  usual 
precautions  are  taken  and  the  indications  which  have  been 
laid  down  are  followed. 

LITERATURE. 

Pribram.  Osteoarthritis  Deformans.  Nothnagel's  Handbuch  d.. 
spez.  Path.     Bd.  vii.      5  Teil. 

ScHUCHARDT.  Krankhciten  der  Knochen  u.  Gelenke.  Stuttgart, 
1899.      Deut.  Chir. 

ScHULLER.  Polyarthritis  Villosa,  etc.  Berl.  khn.  Wochens. 
5-7.      1900. 

W.  MiJLLER.  Operative  Behandlung  der  Arthritis  Deformans. 
Langenbeck's  Arch.     Bd.  xlvii. 

OSTEOMALACIA. 

Etiology. — Frequent  pregnancies  at  short  intervals, 
difficult  labours  with  slow  convalescence,  predispose  to 
the  disease  ;  malnutrition  and  unhealthy  and  damp 
surroundings  also  appear  to  favour  its  onset. 


454  INDICATIONS    FOR    OPERATION    IN 

Pathological  Anatomy. — Osteomalacia  renders  the 
bones  soft  and  brittle.  It  may  be  described  as  a 
chronic  ostitis,  with  decalcification  and  the  formation 
here  and  there  of  masses  of  new  bone  tissue.  The 
decalcification  takes  place  from  within  outwards,  and  is 
not  uniform.  Usually  there  are  multiple  fractures,  which 
do  not  consolidate;  the  deformity  of  the  pelvis  is  charac- 
teristic. 

Symptoms. — The  first  symptoms  are  usually  pain  in  the 
pelvis  and  difficulty  in  movement.  Contraction  of  the 
adductors  prevents  rapid  abduction  of  the  thighs.  At  an 
early  stage  there  is  tenderness  on  pressure  over  the  ribs, 
sternum,  long  bones,  and  pelvis.  When  the  ilia  are  forcibl}^ 
and  rapidly  compressed  there  is  a  sensation  of  resiliency. 
The  patient  becomes  shorter  in  stature,  the  gait  becomes 
awkward  and  waddling,  and  she  usually  requires  a  stick 
or  the  support  of  a  companion.  Curvatures  of  the  bones 
become  marked ;  the  pelvis  acquires  its  characteristic 
beaked  shape,  the  ribs  almost  touch  the  iliac  crests, 
and  the  thorax  is  greatly  deformed.  Spontaneous  frac- 
tures are  common  occurrences.  The  patellar  reflexes  are 
exaggerated. 

At  a  later  stage  contractures  occur  throughout  the  mus- 
cular system,  the  skin  atrophies,  the  muscles  degenerate,  and 
dyspnoea  and  cachexia  supervene. 

The  disease  usually  makes  its  first  appearance  during 
pregnancy ;  labour  takes  place  normally,  and  the  patient 
improves ;  but  if  she  become  pregnant  again  the  disease 
progresses  rapidly,  and  succeeding  pregnancies  still  further 
aggravate  it. 

Dl^gnosis. — The  early  tenderness  of  the  bones,  the  con- 
tracture of  the  adductors,  the  waddling  gait,  and  the  loss 
of  stature  make  the  diagnosis  certain.  It  may  be  confounded 
with  certain  spinal  affections  if  its  characteristics  are  not 
kept  clearly  in  mind,  and  its  symptoms  may  be  in  part 
simulated  in  cases  of  multiple  myeloma  and  of  pseudo- 
leucaemia.  Multiple  myeloma  will  be  distinguished  by  the 
presence  of  albumosuria  and  swelling  of  the  lymphatic 
glands  and  spleen,  by  the  radiographic  examination  of 
the  bone  swellings,  and  the  appearance  of  symptoms  of 
spinal  cord  compression.  In  hysteria  there  are  no  bony 
deformities. 


DISEASES    OF    THE    JOINTS    AND    BONES.         455 

INDICATIONS   FOR   OPERATION. 

Fehling  has  collected  evidence  to  show  that  castration 
can  cure  osteomalacia.  Internal  treatment  with  phosphorus 
is  also  often  successful,  and  therefore  operation  will  only  be 
recommended  under  certain  conditions  (Latzko).  If  the 
patient  is  not  pregnant,  castration  should  be  done  when 
internal  treatment  with  phosphorus  for  six  months  or  more 
has  failed.  In  pregnancy  the  child  should  only  be  considered 
if  medical  treatment  has  succeeded  so  far  as  to  check  the 
symptoms  ;  these  are  aggravated,  as  a  rule,  as  pregnancy 
progresses,  and  when  this  is  the  case  premature  labour 
should  be  induced.  When  treatment  with  phosphorus 
fails  during  pregnancy  and  the  pelvis  is  narrow,  one  should 
be  content  with  procuring  abortion,  because  treatment 
may  be  successful  after  this,  and  a  living  child  born.  If 
pregnancies  rapidly  follow  each  other,  or  if  abortion  is 
frequent,  Porro's  operation  should  be  done,  or  total  extirpa- 
tion through  the  vagina.  When  the  pelvis  is  extremely 
narrow,  and  abortion  cannot  for  that  reason  be  procured, 
Porro's  operation  should  be  done,  with  or  without  castration. 

Contra-indications. — No  operation  will  be  done  unless 
internal  treatment  has  been  tried.  No  success  follows 
operative  treatment  in  the  virgin  or  the  aged,  and  it  will, 
therefore,  be  avoided.  Occasionally  the  affection  is  associated 
with  disease  of  the  central  nervous  system  (tabes,  syringo- 
myelia), and  when  this  is  the  case,  or  when  there  is  some 
other  complication  such  as  tuberculosis,  no  operation  is 
advisable. 

Prognosis. — Risks  of  operation. — These  are  not  slight  in 
any  of  the  methods  recommended.  Sixty-nine  cases  of 
Porro's  operation  for  osteomalacia  published  up  to  1898 
showed  a  mortality  of  nine.  Death  occurred  from  heart 
failure,  bronchitis,  bronchopneumonia,  and  sepsis. 

Results  of  operation. — In  many  cases  removal  of  the  ovaries 
has  permanently  cured  the  disease  ;  in  a  minority  the  con- 
dition has  progressed  in  spite  of  it.  Late  recurrence  has 
been  observed  in  some  cases.  I  have  seen  a  case  in  which 
the  symptoms  advanced  in  spite  of  castration,  and  even  the 
bones  of  the  skull  were  affected  ;  in  another  case  recovery 
was  complete.  Pain  is  usually  very  rapidly  relieved  by 
operation,  and,  as  a  rule,  entirely  disappears  by  degrees. 


456  INDICATIONS    FOR    OPERATION. 

First  the  pains  in  the  bones  of  the  trunk  improve,  and  then 
those  in  the  long  bones.  The  deformities  of  course  remain 
in  spite  of  the  recovery. 

//  no  operation  he  undertaken  internal  treatment  with 
phosphorus  is  often  successful ;  untreated  puerperal  osteo- 
malacia is  fatal  in  80  per  cent  of  cases.  Treatment  with 
phosphorus  can  claim  results  equal  to  those  of  operation, 
and  after  an  experience  of  many  cases,  I  can  endorse  the 
opinion  of  Latzko  that  the  prospects  of  success  with  this 
drug  are  very  favourable  ;  the  pains  diminish,  the  bones 
consolidate  after  some  months  of  treatment,  and  finally 
the  patient  is  able  to  get  about  again.  In  none  of  the  cases 
which  I  have  seen  in  virgins  and  in  puerperal  women  has 
this  treatment  been  without  some  measure  of  success;  in 
senile  osteomalacia  the  results  are  not  so  favourable.  Those 
who  advocate  early  operation  for  this  condition  should  take 
note  of  these  facts,  especially  in  view  of  the  comparative 
risks  of  the  two  methods*. 

LITERATURE. 

V.  WiNKEL.  Osteomalacic.  Handbuch  der  Therapie  innerer 
Krankheiten    (Penzoldt-Stintzing).     2nd    Ed.     Jena. 

Latzko.  Beitr.  zur  Diagnose  u.  Therapie  der  Osteomalacic. 
Monats.  f.  Geburtshilfe  u.  Gynakol.      1897. 

Laufer.  Osteomalacic  des  Weibes.  Zentralb.  f.  d.  Grenzgebicte 
d.  Med.  u.  Chir.      1900. 

ViERORDT.  Osteomalacic.  Nothnagel's  Handbuch  der  spez. 
Path.     Wien. 

ScHUCHARDT.  Krankhcitcn  der  Knochen  u.  Gclenke.  Stuttgart, 
1899.     Deut.  Chir. 

*  In  one  of  my  cases  death  occurred  from  subacute  phosphorus 
poisoning  ;  the  patient  had  much  exceeded  the  daily  dose  prescribed. 


APPENDICES. 


459 


APPENDICES 


Appendix   I. 

INDICATIONS    FOR    THE    INDUCTION    OF 
PREMATURE    LABOUR. 

I  do  not  propose  to  discuss  the  various  obstetric  conditions 
which  call  for  the  induction  of  premature  labour,  such  as 
the  death  of  the  foetus,  narrow  pelvis,  and  the  like,  but  to 
consider  the  circumstances  under  which  it  may  be  necessary 
on  account  of  the  presence  of  some  internal  disease  in  the 
mother.  It  must  be  remarked  that  absolute  indications 
can  be  laid  down  only  in  a  relatively  small  number  of  cases, 
and  that  opinions  on  the  matter  change  considerably  from 
time  to  time. 

CARDIAC    DISEASE. 

If  endocarditis  supervenes  during  pregnancy  it  is  not 
necessary  to  arrest  the  latter  if  the  heart  function  remains 
unimpaired  and  the  organ  retains  its  tone,  that  is  to  say, 
if  signs  of  actual  heart  failure  are  absent.  If  the  endo- 
carditis is  recurrent  in  type ;  if  it  is  associated  with  high 
fever ;  if  dyspnoea,  arythmia,  cyanosis,  and  signs  of  conges- 
tion of  the  liver,  spleen,  and  kidneys  are  present,  and  the 
lower  limbs  are  oedematous :  then  premature  labour  should  be 
induced,  unless  the  condition  improves  rapidly  under  internal 
treatment.  Abortion  and  premature  labour  not  infrequently 
occur  spontaneously  under  such  circumstances. 

If  valvular  disease  or  a  heart  muscle  affection  exists 
when  pregnancy  begins,  it  is  not  necessary  to  induce  labour 
if  compensation  is  satisfactory.  Many  women  pass  through 
pregnancy  without  any  untoward  symptoms  in  spite  of  such 
lesions. 


46o  INDICATIONS    FOR    OPERATION. 

On  the  other  hand,  grave  defects  in  compensation, 
extensive  oedema,  arythmia,  dyspnoea,  pulmonary  and 
hepatic  congestion,  justify  induction  of  labour  in  my  opinion, 
even  if  cardiac  "remedies  diminish  the  symptoms  of  defective 
compensation.  In  such  cases  a  return  of  symptoms  is 
to  be  feared,  and  during  the  further  course  of  the  pregnancy 
they  may  run  a  rapid  course  and  prove  fatal.  But  the 
operation  will  not  be  undertaken  while  the  symptoms  of 
defective  compensation  are  at  their  height,  unless  there  is 
good  reason  to  believe  that  no  further  improvement  under 
treatment  can  be  expected  ;  if  induced  under  such  unfavour- 
able circumstances  the  labour  may  further  embarrass  an 
already  grave  condition. 

When  defective  compensation  is  of  long  standing, 
even  though  only  of  small  degree  and  unassociated 
with  oedema,  premature  labour  should,  in  my  opinion, 
be  induced. 

In  mitral  disease,  particularly  mitral  stenosis,  if  disturb- 
ances of  compensation,  even  of  a  slight  degree,  supervene 
in  the  course  of  pregnancy,  it  is  advisable  to  interfere,  if 
improvement  does  not  rapidly  occur  under  treatment. 
Experience  has  shown  that  it  is  in  this  form  of  cardiac 
disease  that  sudden  and  dangerous  symptoms  are  particu- 
larly liable  to  arise  ;  42  per  cent  of  the  cases  of  this  kind 
reported  in  the  literature  have  ended  fatally,  but  this 
percentage  is  of  course  unduly  high,  the  fatal  cases  being 
those  usually  reported. 

In  general  it  is  legitimate  to  persist  in  expectant 
treatment  in  the  second  half  rather  than  in  the  first 
half  of  pregnancy,  the  strain  on  the  heart  increasing 
only  slightly  during  the  second  half.  Spontaneous  abortion 
occurs  in  about  a  fifth  of  women  suffering  from  heart 
disease. 

If  heart  disease  is  complicated  by  renal  disease,  it  is 
necessary  to  interrupt  pregnancy,  even  if  there  are  no 
defects  of  compensation  ;  the  same  is  also  indicated  in 
the  rare  association  of  recent  phthisis  and  cardiac 
disease. 

Labour  may  be  induced  in  cases  of  well-compensated 
heart  disease  by  the  bougie  ;  in  grave  disturbance  of 
compensation  with  pulmonary  oedema  by  puncturing  the 
membranes. 


INDUCTION    OF    PREMATURE    LABOUR.  461 

LITERATURE. 

Baranger.     Cardiopathies  et  Grossesses.     Tliese  de  Paris.      1898. 

Fellner.  Die  Beziehungen  innerer  Krankheiten  zu  Scliwanger- 
schaft,  Geburt,  u.  Wochenbett.     Wien  :  Deuticke.      1903. 

Luck.     Mitral  Stenosis  in  Pregnancy.     Med.  News,  1893. 

LwoFF.  Maladies  du  Coeur  et  Grossesse.  Annales  du  Gynec.  et 
d'Obstetr.     T.  xlviii.,  p.  489. 

Marier.  On  Cardiac  Disease  During  Pregnancy.  Amer.  Journ. 
of  Gynsec.  and  Paed.     x.,  1895. 

R.  PoLLAK.  Herzfehler  und  Schwangerschaft.  Zusammen- 
iassendes  Referat.  Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
1902. 


DISEASES   OF    THE    RESPIRATORY   ORGANS. 

Laryngeal  Tuberculosis. — There  is  general  agreement  on 
the  fact  that  laryngeal  phthisis  progresses  rapidly  during 
pregnancy,  and  may  give  rise  to  alarming  symptoms. 
I  have  seen  this  rapid  progress  of  the  disease  in  several  of 
my  own  cases.  The  induction  of  premature  labour  has 
■consequently  been  urged  in  this  condition  by  many  authori- 
ties ;  it  should  be  done  as  soon  as  possible  once  the  diagnosis 
has  been  definitely  established.  The  progress  of  the  disease 
is  usually  arrested  by  the  operation  ;  if  it  is  not  done  it  is 
often  necessary  to  have  recourse  to  tracheotomy. 

Pulmonary  Tuberculosis. — As  in  the  case  of  laryngeal 
■disease,  pulmonary  phthisis  is  usually  aggravated  by 
pregnancy.  Old-standing  stationary  disease  becomes 
progressive,  and  recent  disease  progresses  with  increased 
rapidity.  Florid  tuberculosis  or  subacute  miliary  tuber- 
culosis is  thus  found  by  no  means  rarely  among  pregnant 
women,  and  most  authorities  counsel  the  induction  of  labour, 
the  only  difference  of  opinion  being  as  to  the  stage  at  which 
it  should  be  brought  about.  Thus  Paddok  would  undertake 
it  only  when  the  child  has  reached  a  viable  age  ;  Heymann 
advises  it  when  there  is  evidence  that  the  pregnancy  is 
influencing  the  lung  condition  unfavourably  ;  whilst  Acconi 
recommends  it  even  when  the  disease  is  in  an  early  stage. 

From  my  own  experience,  and  a  study  of  the  literature 
on  the  subject,  the  following  indications  appear  to  me  to  be 
sound  : — 

I.  When  a  case  of  old-standing  phthisis  shows  signs  of  a 
reawakening  of  the  disease,  however  moderate,  with  the 


462  INDICATIONS    FOR    OPERATION. 

onset  of  pregnancy  ;  for  example,  when  fever  or  an  attack 
of  hgemoptysis  supervenes,  abortion  or  premature  labour 
should  be  induced  at  once  ;  in  several  instances  of  this  kind 
where  I  have  delayed  I  have  seen  florid  tubercle  or  miliary 
tubercle  develop. 

2.  When  the  physician,  from  previous  knowledge  of  the 
patient,  is  aware  of  the  presence  of  the  so-called  erethic 
form  of  tuberculosis,  pregnancy  should  be  interrupted  as 
early  as  possible,  to  escape  the  development  of  fatal  lesions 
in  the  lungs. 

3.  When  pulmonary  tubercle  is  associated  with  other  foci 
of  the  disease  elsewhere,  the  induction  of  premature  labour 
is  absolutely  indicated. 

4.  It  is  advisable  even  in  stationary  tubercle,  when  the 
patient  is  a  multipara,  and  it  is  known  that  the  pulmonary 
disease  has  increased  in  gravity  during  previous  pregnancies. 

5.  Some  writers  have  expressed  the  view  that  in  the  case 
of  miliary  tubercle  the  induction  of  labour  should  be  delayed 
with  a  view  to  obtaining  a  living  child.  With  this  opinion 
I  do  not  agree.  The  disease  in  the  mother  is  aggravated 
by  the  pregnancy,  and  there  is  no  guarantee  that  a  healthy 
child  will  be  obtained. 

Pneumonia. — Abortion  or  premature  labour  often  occurs 
spontaneously  in  this  disease.  Judging  from  the  literature, 
it  may  be  expected  in  about  half  of  the  cases,  although 
Fellner's  statistics  do  not  show  so  high  a  percentage  as  this. 
Seeing  that  labour  throws  extra  strain  on  the  already  over- 
tried  heart,  and  that  experience  shows  that  pulmonary 
oedema  is  especially  to  be  feared  in  cases  in  which  abortion 
takes  place,  it  is  generally  unwise  to  induce  labour.  Accord- 
ing to  Fischer,  the  mortality  in  patients  who  are  left  alone 
is  about  14  per  cent,  in  cases  in  which  labour  is  induced 
about  72  per  cent. 

Pleurisy. — In  pleurisy  the  case  is  very  much  the  same  as 
in  pneumonia.  Since  labour  adds  increased  risk  to  the 
attack,  and  the  latter  as  a  rule  has  no  harmful  influence  on 
the  further  progress  of  the  pregnancy,  the  induction  of 
abortion  or  premature  labour  is  inadvisable. 

LITERATURE 

AccoNi.     Tuberculosi     e     Gravidanza.     La     Clinica     Moderna. 
Firenze.      1895. 


INDUCTION    OF    PREMATURE    LABOUR.  463 

Boyd.  The  Indications  for  and  Technique  of  the  Induction  of 
Premature  Labour.     Albany  Med.  Annals,  xviii.,  1897. 

Chop.  Tuberculose  Pulmon.  et  Grossesse.  Arch,  de  Tocol.  et 
Gynecol.,  viii.,  1894. 

Durante.  Tuberculosi  e  Puerperalita.  La  Riforma  Medica, 
Vol.  viL,  1898. 

Fellner,  Otto.  Die  Beziehungen  innerer  Krankheiten  zu 
Schwangerschaft,  Geburt,  u.  Wochenbett,  p.  19  ff.  Wien  : 
Deuticke.      1903. 

Hantke.  Die  Medizinischen  Indikationen  zur  Unterbrechung 
der  Schwangerschaft.  Sammelbericht.  Monatsschr.  f.  Gynak. 
H.  iii:      1902. 

HiGGiNS.  The  Propriety,  Indications,  and  Methods  for  the 
Termination  of  Pregnancy.  Jour.  Amer.  Med.  Assoc,  November  19, 
1904. 

Kammer.  Ueber  den  Einfiuss  von  Schwangerschaft  und  Ent- 
bindung  auf  den  phthisischen  Prozess.  Deut.  ■  med.  Wochens. 
No.  35,      1901. 

Kuttner.  Larynxtuberkulose  und  Graviditat.  Deut  Aerzte- 
Zeitung,  Heft  22,  1901. 

ScHOHL.    Pneumonic  et  Grossesse.     Presse  Medicale,  p.  491,  1896. 

Wilson.  Phthisis  in  Pregnancy.  Amer.  Journ.  of  Obstr.,  Vol. 
xxxix.,  1899. 


DISEASES    OF    THE    BLOOD. 

According  to  Sanger,  pregnancy  aggravates  the  course 
of  Leuccsmia.  This  author  and  Fellner  advise  that,  if  the 
disease  is  not  of  a  serious  type,  premature  labour  should 
not  be  induced  until  there  is  a  prospect  of  obtaining  a 
living  child,  but  that  if  the  type  is  grave  and  the  symptoms 
increase  in  severity  on  the  onset  of  pregnancy,  labour  should 
be  induced  without  delay. 

In  Progressive  Pernicious  Ancemia  the  production  of 
abortion  is  not  indicated  in  the  interests  of  the  mother ;  it 
cannot  save  her,  and  only  hastens  the  progress  of  the 
disease.  It  is  also  contra-indicated  in  the  interests  of  the 
child,  except  in  an  occasional  case. 

In  Scorbutus  and  in  the  rare  condition  of  HcEmophilia  in 
the  female,  profuse  haemorrhage  is  to  be  feared,  whether 
parturition  takes  place  naturally  or  is  brought  on  artificially. 
No  case  of  fatal  post-partum  haemorrhage  due  to  these 
affections  is,  however,  on  record,  and  in  view  of  this  and 
the  fact  that  induction  of  labour  has  no  particular  influence 
in  arresting  or  improving  the  diseases  in  question,  it  is  not 
advisable  to  interfere. 


464  INDICATIONS    FOR    OPERATION. 

States  of  marked  Cachexia,  resulting  from  malignant 
growths,  malaria,  and  other  affections,  call  for  the  induction 
of  abortion,  with  a  view  to  giving  the  patient  relief.  There 
is  no  necessity  to  consider  the  matter  from  the  point  of  view 
of  the  child,  as  in  most  cases,  even  when  the  pregnancy 
goes  on  to  term,  a  viable  infant  is  hardly  ever  obtained. 

LITERATURE. 

O.  Fellner.  Beziehungen  innerer  Krankheiten  zur  Schwanger- 
schaft.     Wien  :  Deuticke.      1903. 

Merttens.  Chorea  und  Leukamie  als  Indikationen  zur  Ein- 
leitung  des  kiinstlichen  Abortus.  Monatsschr.  f.  Gynak.  H.  xii., 
1900. 

PiNARD.  L'Avortement  Medicalement  Provoque.  Annal.  de 
Gynec,  1899. 

W.  Stempel.  Die  Hamophilie.  Zusammenfassendes  Referat. 
Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1900 

ViNAY.  Traitement  de  I'Anemie  Pernicieuse  de  la  Puerperalite. 
Med.  Moderne.     Paris,  1898. 


THE    INFECTIOUS    FEYERS. 

In  most  of  the  acute  infective  fevers  the  interruption  of 
pregnancy  is  contra-indicated,  as  the  effect  on  the  mother 
is  to  aggravate  the  disease. 

In  Enteric  Fever  labour  brings  with  it  increased  risk  of 
pulmonary  complications,  intestinal  haemorirhage,  and 
perforation.  In  many  cases  the  course  of  pregnancy  is 
not  interrupted  by  the  disease,  and  it  is  useless  and  dangerous 
to  induce  labour  artificially.  In  two  cases  under  my  care 
the  patients  passed  through  an  attack  without  accident ; 
in  a  third  case,  of  a  severe  type,  labour  came  on  only  when 
a  relapse  supervened,  and  a  living  child  was  born. 

In  Scarlatina  induction  of  labour  is  contra-indicated, 
■on  account  of  the  danger  of  septic  infection  ;  the  same  is 
true  of  Small-pox  and  Diphtheria,  and,  in  my  opinion,  of 
Erysipelas,  although,  according  to  Fellner,  intervention 
can  be  undertaken  in  the  latter  without  this  risk.  I  have 
never  come  across  a  case  in  which  it  was  necessary. 

Measles  is  especially  dangerous  during  the  puerperium, 
so  that  labour  should  never  be  induced  in  this  disease.  It 
is  necessary  in  the  course  of  Influenza  only  when  there  are 
complications  which  specially  call  for  it. 


INDUCTION     OF    PREMATURE    LABOUR.  465 

In  Tetanus  the  attacks  are  liable  to  be  increased  in  severity 
if  labour  comes  on  ;  therefore  it  is  never  to  be  induced.     . 

In  Malaria,  if  the  attack  is  slight  or  only  of  mean  severity, 
there  is  no  necessity  to  interfere  ;  but  if  the  condition  is 
one  of  marked  malarial  cachexia,  pregnancy  should  be 
terminated ;  it  seriously  compromises  recovery,  and  with 
the  mother  in  this  condition  the  child  is  usually  ill-developed 
and  rarely  lives. 

LITERATURE. 

Abrahams.  Influenza  in  Puerperal  Women.  Medical  Record; 
1898. 

Archambrand.  Le  Tetanos  pendant  la  Grossesse.  La  Rev. 
Med.     Dec,   1896. 

Bar  et  Boulle.     Grippe  et  Puerperalite.     L'Obstetric,  iii.,  1898. 

CuRSCHMANN.  Der  Abdominaltyphus.  Nothnagel's  Handbuch 
der  spez.  Pathol,  u.  Therap.     Wien. 

Edmonds.     Malaria  and  Pregnancy.     Brit.  Med.  Jour.,  1899. 

O.  Fellner.  Die  Beziehungen  innerer  Krankheiten  zu 
Schwangerschaft,  etc      Wien:   Deuticke.      1903. 

Mangiagalli.  Ileotifo  in  Gravidanza.  Arch.  Ital.  die  Ginec. 
Napoli,  1 90 1. 

Salus.  Masern  in  der  Schwangerschaft.  Prager  med.  Wochens., 
1899. 

ViNAY.     Variole  dans  la  Grossesse.     Lyon  Medicale.     Mar.,  1900. 

Zampetti.  LTnfluenza  nel  Parto.  Gaz.  degli  Ospedali.  Milano, 
1901. 

DISEASES    OF    THE    KIDNEY.     ECLAMPSIA. 

Albuminuria  occurs  in  a  relatively  large  number  of 
pregnant  women.  The  onset  of  nephritis,  with  abundant 
elimination  of  corpuscular  elements  and  albumin,  although 
not  so  common,  occurs  in  a  considerable  number,  and  the 
question  of  terminating  pregnancy  by  artificial  means 
often  arises  in  connection  with  this  condition.  Cases  in 
which  nephritis  has  been  present  before  the  pregnancy 
commenced  offer  the  same  problems. 

If  albumin  and  casts  are  found  in  the  urine,  and  no 
alarming  symptoms  are  present,  it  is  advisable  to  leave 
things  alone  for  a  short  time  and  see  the  effect  of  a  milk 
•diet.  If  the  albumin  and  casts  diminish  under  this  regime 
the  pregnancy  may  be  allowed  to  run  its  course,  the  patient 
meanwhile  being  watched  with  great  care.  If,  however, 
any   dangerous   symptoms   arise,   or   if  the   signs   of  renal 

30 


466  INDICATIONS    FOR    OPERATION. 

irritation  do  not  completely  disappear  in  the  course  of 
about  a  fortnight  under  strict  milk  diet,  it  is  necessary  to 
procure  abortion  or  labour  as  the  case  may  be. 

The  following  must  be  interpreted  as  dangerous  symptoms : 
reduction  in  the  amount  of  the  urine,  marked  oedema  of 
the  legs  or  elsewhere,  severe  headache,  frequent  vomiting 
dating  from  the  onset  of  the  renal  symptoms,  paralytic 
phenomena,  increase  in  the  amount  of  albumin,  and  signs 
of  cardiac  disturbance.  If  albuminuric  retinitis  or  urgemic 
amaurosis  supervene,  intervention  is  urgent,  and  the  risk 
of  delay  great  ;  according  to  Silex,  of  22  cases  with  these 
symptoms  6  became  blind,  and  in  10  the  sight  was 
permanently  damaged. 

Pregnancy  is  associated  with  great  risk  to  a  patient  with 
chronic  nephritis,  and  it  is  justifiable  to  interrupt  it  ; 
according  to  Fellner  the  mortality  in  this  condition  is  40^ 
per  cent,  but  this  figure  is  based  on  a  small  number  of  cases 
only.  Eclampsia  occurs  in  a  third  of  these  cases.  If  the 
patient  has  already  passed  through  the  first  half  of  her 
time  when  first  seen,  without  any  untoward  symptoms,, 
it  is  justifiable  to  wait  until  a  living  child  may  be  expected, 
and  then  induce  labour.  The  mother  must,  of  course,  be 
carefully  watched  during  this  time  of  waiting. 

When  there  is  a  history  of  nephritis  during  a  previous 
pregnancy  from  which  the  patient  recovered,  the  progress 
of  events  must  be  watched,  and  if  signs  of  the  disease 
reappear  labour  must  be  brought  on.  Of  26  such  cases 
in  Schauta's  clinic  22  showed  no  renal  symptoms  during 
the  later  pregnancy. 

Eclampsia  constitutes  a  vital  indication  for  terminating 
pregnancy  if  the  attacks  are  in  the  least  degree  frequent 
or  severe.  The  mortality  is  12 '5  per  cent  in  Fellner's 
tables  ;  other  writers  give  a  higher  figure  (Schniirer  21  per 
cent).  I  would  not  hesitate  for  a  moment  to  recommend 
immediate  interference  after  a  single  attack  of  any  severity. 
Intervention  offers  practically  the  only  hope  if  the  patient 
is  in  a  state  of  coma  following  eclampsia. 

In  the  presence  of  slight  seizures  some  obstetricians 
recommend  waiting,  provided  the  attacks  do  not  follow 
one  another  rapidly,  and  the  patient  is  in  good  condition 
in  the  intervals. 

In  about  half  the  cases  labour  ends  the  seizures  (Schniirer) ;, 


INDUCTION    OF    PREMATURE    LABOUR.  467 

others  record  higher  percentages  of  recovery,  up  to  80  per 
cent.  Intervention  should  be  practised  under  deep 
anaesthesia. 

Hcematuria  of  renal  origin  presents  the  same  indications 
as  albuminuria.  It  may  be  present  as  one  of  the  signs 
of  nephritis.  When  due  to  some  other  renal  condition  it 
will  necessitate  interruption  of  pregnancy  if  oft  repeated 
and  copious  ;  the  pregnancy  aggravates  the  tendency 
to  haemorrhage. 

If  Pyelonephritis  is  discovered  in  a  pregnant  woman,  and 
if  ordinary  therapeutic  measures  have  no  marked  effect, 
abortion  should  be  procured.  But  if  the  affection  has 
developed  during  the  pregnancy,  and  no  dangerous  symp- 
toms are  present,  it  is  justifiable  to  wait  until  a  living  child 
can  be  obtained,  and  then  induce  premature  labour. 

LITERATURE. 

Anderodias.  Pyelonephrite  dans  la  Grossesse.  Compt.  Rend, 
de  la  Societe  Obstetr.  de  Paris,   1901. 

CoNDRAY.  Des  Indications  de  ITnterruption  de  la  Grossesse  chez 
les  Femmes  Enceintes  Albuminuriques.     These  de  Paris,  1900. 

O.  Fellner.  Die  Beziehungen  innerer  Krankheiten  zu 
Schwangerschaft,  etc.     Wien :  Deuticke.      1903. 

A.  Manry.  Le  Traitement  de  FEclampsie  Puerperale.  These 
de  Paris,  1903. 

Marx.  The  Indications  for  Premature  Delivery,  etc.  Med.  News. 
June,  1900. 

Miranda.  La  Patogenesi  e  la  Cura  dell'  Eclampsia  Puerperale. 
Arch,  di  Ost.  et  Gyn.,  ix.,  1899. 

Pestalozza.     Eclampsia   Puerperalis.     Firenze.      1900. 

ScHNTJRER.  Ueber  die  Puerperaleklampsie.  Kritischer  Sammel- 
bericht.     Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir.,  1903. 

ScHULZ.  Treatment  of  Albuminuria  of  Pregnancy.  Annals  of 
Gyn.  and  Ped.,  1900. 

Thiebaud.  Hematurie  de  la  Grossesse.  Jour,  de  Med.etde 
Chir.,  Tome  Ixxxi. 

Webster.  Affections  of  the  Kidney  in  Relation  to  Pregnancy. 
Journ.  Amer.  Med.  Assoc,  April,  1900. 


DISEASES   OF    THE    STOMACH. 

HcBmatemesis. — Haematemesis  is  met  with  from  time  to 
time  in  pregnant  women,  and  is  usually  due  to  gastric  ulcer. 
If  it  docs  not  yield  to  careful  medical  treatment,  and  recurs 
to  such  a  degree  as  to  threaten  a  fatal  issue,  the  pregnancy 


468  INDICATIONS    FOR    OPERATION. 

must  be  interrupted  to  enable  complete  rest  to  be  given 
to  the  stomach.  The  question  will  sometimes  arise  during 
the  second  half  of  pregnancy,  and  premature  labour  may 
then  be  indicated  with  a  view  to  obtaining  a  living  child. 

Hypereniesis  Gravidarum. — In  the  great  majority  of 
•cases  this  is  a  transitory  condition,  or  can  be  checked 
sufficiently  to  avoid  any  serious  risk  to  the  mother.  If, 
however,  all  internal  and  external  methods  of  treatment 
have  been  exhausted  without  success,  and  the  vomiting 
continues  to  such  a  degree  that  the  development  of  a  viable 
child  becomes  doubtful,  it  is  justifiable,  and  under  such 
circumstances  often  absolutely  necessary,  to  bring  the 
pregnancy  to  an  end.  This,  however,  must  be  looked 
upon  only  as  a  last  resource,  when  all  other  methods  have 
failed. 

In  a  case  which  I  saw  several  times  in  consultation  during 
the  second  month  of  pregnancy,  the  patient  was  so  reduced 
by  a  fortnight's  persistent  vomiting  that  her  life  was  seriously 
endangered.  She  vomited  incessantly  day  and  night,  she 
wasted  rapidly,  and  her  condition  was  one  of  collapse,  with 
subnormal  temperature  and  starvation-delirium.  Abortion 
was  procured,  and  she  rapidly  recovered  from  her  very 
dangerous  state. 

LITERATURE. 

CoRADESCHi.  Ematemesi  durante  la  Gravidanza.  Gaz.  d. 
Osped.   e  delle  Cliniche,    1898. 

Fellner.  Die  Beziehungen  innerer  Krankheiten  zu  Schwan- 
gerschaft,  Geburt,  u.  Wochenbett.     Wien  :   Deuticke.      1903. 


APPENDICITIS. 

Appendicitis  during  pregnancy  is  not  rare.  Most  writers 
have  taken  a  very  grave  view  of  this  complication,  and, 
judging  from  recorded  cases,  the  mortality  is  very  high. 
As  a  matter  of  fact  the  combination  is  not  a  particularly 
dangerous  one.  I  have  seen  a  considerable  number  of 
first  attacks  of  appendicitis  which  supervened  during 
pregnancy.  Perhaps  there  is  an  element  of  chance  in  the 
fact  that  none  of  these  cases  were  fatal,  nor,  in  fact,  presented 
any  particularly  serious  symptoms.  Labour  during  appen- 
dicitis certainly  increases  the  risk  of  the  latter ;  an  abscess 


INDUCTION    OF    PREMATURE    LABOUR.  469 

may  rupture  or  the  process  may  extend  after  delivery, 
and  induction  of  labour  is  contra-indicated.  It  not 
uncommonly  occurs  spontaneously.  Fellner's  view  that 
in  the  catarrhal  form  of  the  disease  the  induction  of  labour 
might  be  advantageous,  is  really  only  of  theoretical  interest, 
as  we  have  no  certain  guides  to  distinguish  the  purulent 
from  the  non-purulent  type.  If  it  is  necessary  to  intervene 
in  a  case  where  appendicitis  is  complicated  by  pregnancy, 
the  appendix,  not  the  uterus,  should  be  attacked. 

LITERATURE. 

Jarca.  Contribution  a  I'Etude  de  I'Appendicite  pendant  la 
Grossesse.     These  de  Paris,    1898. 

Keiler.  Perityphlitis  und  Graviditat.  Miinch.  med.  Wochens., 
No.  18,   1902. 

KoNiG.  Appendicitis  und  Geburtshilfe.  Hegar's  Beitrage.  Bd. 
ii.      1900. 

McRae.  Appendicitis  in  the  Female.  New  York  Med.  Jour., 
■1900. 

PiNARD.  Nouveaux  Documents  pour  Servir  a  I'Histoire  de 
I'Appendicite  dans  ses  Rapports  avec  la  Grossesse.  Annal.  de 
Gynec,  Tome  liii.,  1900. 

Pollack.  Appendicitis  und  weibliches  Genitale.  Centralb.  f. 
d.  Grenzgebiete  d.  Med.  u.  Chir.     No.   5  u.  ff.      1904. 


DISEASES    OF    THE    LIYER. 

Cholelithiasis. — The  frequency  of  attacks  of  biliary  colic 
during  pregnancy  is  recognized ;  they  are  at  any  rate  not 
uncommon.  They  are  often  of  a  severe  type  and  associated 
with  fever.  It  is  never,  however,  necessary  to  provoke 
labour  on  account  of  such  attacks  ;  if  interference  is  neces- 
sary, operation  for  removal  of  the  biliary  calculi  is  what  is 
indicated. 

Jaundice. — The  so-called  "  icterus  gravidarum,"  which 
is  a  very  rare  affection,  is  an  indication  for  the  induction 
of  premature  labour.  It  is  characterized  by  subcutaneous 
and  submucous  haemorrhages,  with  high  fever  and  delirium, 
and  leads  up  to  acute  atrophy  of  the  liver.  It  attacks 
women  at  about  the  mid-period  of  pregnancy,  and  appears 
to  be  favourably  influenced  by  the  termination  of  the  preg- 
nancy. If  the  affection  is  diagnosed,  it  is  necessary  to 
bring  on  abortion  or  labour  without  delay. 


470  INDICATIONS    FOR    OPERATION. 

LITERATURE. 

H.  Benedikt.  Zur  Kenntnis  des  Schwangerschaftsikterus. 
Deut.  med.  Wochens..  Xo.  i6,  1902. 

Chiavextone.  Atrofia  Giallo  Acuta  in  Gravidanza.  Annal. 
Ost.  e  Gin.,  1899. 

Le  ^Iassox.  Les  Icteres  et  la  Colique  Hepatique  chez  les  Femmes 
en  etat  de  la  Puerperalite.     Paris.      1898. 

Young.  Simple  and  ^Malignant  Jaundice  of  Pregnancy.  Medical 
News,  1898. 


DISEASES    OF    THE    NERVOUS    SYSTEM. 

Hysteria. — It  is  generally  held,  and  with  the  opinion  I 
agree,  that  even  in  the  case  of  hysteria  of  a  very  severe 
type  it  is  very  rarely  necessary  to  end  the  pregnancy 
artificially.  Such  a  necessity  may  arise  occasionally,  for 
example,  if  a  patient  refuses  to  take  food  and  vomits 
repeatedly  when  forcibly  fed  ;  but  in  the  great  majority  of 
hysterical  patients  there  is  no  need  for  interference. 

Epilepsy. — According  to  Binswanger,  pregnancy  often 
exercises  a  harmful  influence  on  the  course  of  this  disease, 
and  results  in  permanent  aggravation.  If  the  attacks 
become  more  frequent  in  spite  of  suitable  treatment,  if 
they  are  of  a  severe  type  and  the  free  intervals  become 
shorter,  if  psychic  symptoms  supervene  which  were  not 
present  before  the  pregnancy,  it  is  necessary,  in  the  opinion 
of  many  authors,  to  procure  abortion.  In  my  opinion,  the 
necessity  is  urgent  under  such  circumstances  ;  there  is  an 
imminent  risk  of  the  onset  of  a  status  epilepticus  and  a  fatal 
ending. 

Chorea. — Chorea  gravidarum  is  an  affection  in  which  the 
prognosis  is  grave,  and  differs  in  this  respect  entirely  from 
ordinary  chorea.  The  mortality  is  very  high,  and  according 
to  Schrock  and  Rust  reaches  25  per  cent.  Some  of  the 
fatalities  occur  during  labour  itself,  and  this  is  a  critical 
time.  Of  95  women  delivered  at  term,  8  died  in  labour 
(Schrock)  ;  delivery  in  the  earlier  months  is  much  less 
dangerous. 

The  disease,  therefore,  makes  it  necessary  to  terminate 
pregnancy  in  the  first  few  months  whenever  possible,  if 
the  woman  is  to  be  saved  from  serious  risk.  If  the  pregnancy 
is   already   far  advanced  when   the   patient   is    lirst    seen. 


INDUCTION    OF    PREMATURE    LABOUR.  471 

premature  labour  will  only  be  induced  if  she  is  already 
much  enfeebled  and  is  the  subject  of  psychic  disturbances. 
Once  the  pregnancy  has  passed  its  mid-term,  labour  becomes 
as  serious  a  risk  artificially  procured  as  when  it  is  allowed 
to  take  place  naturally  ;  it  wiU,  therefore,  be  induced  during 
this  period  only  when  the  enfeeblement  or  psychic  troubles 
referred  to  have  supervened. 

Tetany. — The  painful  cramps  of  tetany  usually  disappear 
after  labour.  Although  the  affection  is  painful  and  distressing 
it  is  not,  as  a  rule,  associated  with  any  danger,  and  there  is 
usually  no  necessity  to  induce  labour.  If,  however,  the 
seizures'  are  very  frequent  and  tend  to  increase  in  duration, 
and,  as  I  have  seen,  hardly  give  the  patient  an  hour's  peace, 
when  the  infant  is  viable,  it  is  an  act  of  humanity  to  induce 
labour. 

If  the  attacks  become  generalized  and  involve  laryngeal 
and  respiratory  muscles,  it  is  necessary  to  terminate  the 
pregnancy  without  delay,  as  the  risk  to  life  under  these 
circumstances  is  great. 

Polyneuritis  Gravidarum. — If  a  severe  type  of  polyneuritis 
involving  the  upper  and  lower  limbs  supervenes  during 
pregnancy,  and  if  no  cause  other  than  the  pregnancy  can 
be  discovered,  it  is  advisable  to  induce  abortion  or  prema- 
ture labour,  on  account  of  the  very  serious  prognosis  of  this 
form  of  the  disease.  In  such  cases,  if  the  pregnancy  is 
allowed  to  continue,  the  motor  and  sensory  phenomena  tend 
to  increase  in  severity  and  to  extend  to  new  regions, 
whereas  if  the  pregnancy  is  brought  to  an  end  the  inflam- 
matory affection  of  the  nerves  rapidly  disappears. 

LITERATURE. 

BiNSWANGER.  Die  Epilepsie.  Nothnagel's  Handbuch  d.  spez. 
Pathol,  u.  Ther.     Wien.      1899. 

Dakin.     Five  Cases  of  Chorea  in  Pregnancy.     Practitioner,  1897. 

O.  Fellner.  Die  Beziehungen  innerer  Erkrankungen  zu 
Schwangerschaft,  Geburt,  u.  Wochenbett.    Wien:  Deuticke.    1903. 

V.  Frankl-Hochwart.  Die  Tetanic.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Ther.     Wien.      1897. 

Jolly.  Die  Indikationen  des  kiinstlichen  Abortus  bei  der 
Behandlung  von  Neurosen  und  Psychosen.  Versammlung  Deutscher 
Naturf.  u.  Aerzte,  Ixxiii.,    1901. 

Mastin.     Chorea  Gravidarum.     These   de   Lyon,    1900. 

Mattiesen.  Zur  Kenntnis  der  Neuritis  Puerperalis.  Arch.  f. 
Gynakologie,  Bd.  Ixiii. 


472  INDICATIONS    FOR    OPERATION. 

Merttens.  Chorea  als  Indikation  zur  Einleitung  des  kxinstlichen 
Abortus.     Monatsschr.  f.  Gynakologie,  Vol.  xii.,    1900. 

PiNARD.  De  rAvortement  Medicalement  Provoque.  Annal.  de 
Gynecol,  1899. 

Stembo.  Schwangerschaftspolyneuritis  nach  unstillbarem  Er- 
brechen.     Deut.  med.  Wochens.,  No.   29,  1895. 

Stewart.  Puerperal  Polyneuritis.  Philad.  Med.  Jour.,  May, 
1901. 

Thomas.  Tetany  in  Pregnancy.  Johns  Hop.  Hosp.  Bull.,  May, 
1895. 


473 


Appendix   II. 
OPERATIONS    ON    DIABETICS. 

The  frequency  of  diabetes,  and  the  fact  that  surgical 
comphcations  are  not  uncommon  in  the  disease,  makes  the 
discussion  of  the  indications  for  and  contra-indications  to 
operation  often  necessary. 

The  indications  have  to  be  considered  from  two  points 
of  view  :  (i)  The  indications  for  operation  in  the  case  of 
actual  complications  of  the  disease  ;  (2)  The  indications 
for  operation  in  affections  which  are  not  etiologically 
connected  witli  the  diabetes  itself. 

The  most  frequent  surgical  complications  of  diabetes 
are  :  gangrene  of  the  lower  limbs,  perforating  ulcer  of  the 
foot,  diabetic  mastoiditis,  phlegmonous  or  gangrenous 
inflammations  of  the  skin,  carbuncle,  cataract. 

I.  The  indications  for  operation  in  the  complications  of 
diabetes. 

(a.)  In  all  surgical  inflammatory  complications  of  diabetes 
it  is  necessary  to  operate  if  the  complication  involves  risk 
to  life  whether  the  diabetes  is  slight  or  severe  in  type. 

(b.)  In  inflammatory  diabetic  gangrene,  operation  must 
not  be  delayed  if  diet  and  conservative  treatment  do  not 
arrest  the  progress  of  the  condition,  and  also  if  there  are 
signs  of  threatening  general  infection,  lymphangitis,  rapid 
pulse,  and  high  fever. 

(c.)  When  operation  is  not  urgent,  almost  all  writers 
advise  the  reduction  of  sugar  to  the  lowest  possible  point 
before  it  is  undertaken  ;  but  when  the  diabetes  is  of  a  mild 
type  this  preliminary  treatment  is  thought  unnecessary 
by  many  (Korner,   Sternberg). 

{d.)  In  diabetic  cataract  operation  may  be  undertaken 
as  soon  as  the  cataract  is  sufficiently  ripe  ;  antidiabetic 
treatment  is  useful,  but  it  is  not  necessary  to  wait  until 
tlie  sugar  has  gone  from  the  urine. 


474  INDICATIONS    FOR    OPERATION 

Many  surgeons  advise  operation  in  the  inflammatory 
complications  if  the  pain  is  severe  and  the  patient  cannot 
be  well  looked  after.  In  the  non-inflammatory  type  of 
gangrene  it  is  advisable  on  the  other  hand  to  await  the 
formation  of  a  line  of  demarcation,  and  meanwhile  to 
institute  antidiabetic  treatment. 

Contra-indications. — When  there  is  no  urgent  call  for 
operation,  it  should  be  avoided  in  severe  diabetes  with 
diaceturia  ;  if  it  is  necessary  to  operate  under  such  cir- 
cum.stances,  a  general  anaesthetic  should  be  avoided  if 
possible. 

2.  When  are  operations  allowable  in  diabetes  ?  When 
a  diabetic  has  some  other  affection  which  will  endanger 
life  if  left  alone,  most  physicians  and  surgeons  agree  that 
operation  should  not  be  delayed.  A  malignant  growth 
is  an  example  of  such  an  affection. 

If  it  is  possible,  however,  to  wait  awhile,  the  sugar  should 
be  reduced  as  much  as  possible.  In  the  opinion  of  many 
it  is  not  necessary  to  delay  until  the  sugar  has  disappeared 
from  the  urine,  but  operation  should  not  be  done  if  acetone 
and  acetic  acid  are  present. 

"  In  many  cases  the  time  for  operation  is  when  treatment 
has  freed  the  urine  of  sugar  "  (Kausch).  One  will  hesitate 
less  when  the  operation  called  for  is  only  a  slight  one,  and 
the  necessary  narcosis  short.  Regnier's  view  that  absence 
of  patellar  reflex  is  a  strict  contra-indication  to  operation 
is  not  now  entertained. 

Contra-indications. — Operations  which  are  not  absolutely 
necessary,  such  as  cosmetic  and  orthopaedic  procedures, 
are  not  advisable  in  the  presence  of  diabetes.  The  disease 
is  always  an  argument  against  operation.  Operations 
which  require  a  prolonged  anaesthesia  should  not  be  done 
unless  for  some  affection  which  threatens  life.  Furunculosis, 
gangrene,  and  other  such  complications,  are  generally  to 
be  viewed  as  contra-indications  to  operation  elsewhere. 
Other  contra-indications  are  acetonuria  and  diaceturia, 
advanced  arteriosclerosis,  signs  of  heart  muscle  degeneration, 
and  marked  albuminuria. 

The  risks  of  operation. — In  a  considerable  number  of 
cases  diabetic  coma  has  supervened  directly  on  narcosis  ; 
this  consequence  is  especially  to  be  feared  if  diacetic  acid 
is  present  in  the  urine  before  operation.     It  is  true  that 


ON    DIABETICS.  475 

many  surgeons  have  seen  no  instance  of  coma  among  a 
large  number  of  cases  (Gersuny-Sternberg  85  cases). 

It  does  not  appear  to  be  of  any  moment  whether  ether 
or  chloroform  is  employed,  but  many  prefer  the  former. 

Coma  may  also  supervene  some  days  after  operation. 
In  100  cases  of  diabetic  gangrene  recorded  by  Wolf  with 
50  deaths,  19  died  from  coma  ;  of  22  of  the  fatal  cases 
who  were  not  operated  on,  coma  was  the  cause  of  death 
in  6  (27  per  cent),  whereas  it  was  responsible  in  13 
cases  (46  per  cent)  out  of  28  on  whom  an  operation 
was  performed. 

In  several  cases  serious  hsemorrhage  has  been  recorded 
.either  at  or  after  the  operation,  apparently  to  be  ascribed 
to  some  affection  of  the  small  vessels. 

Wounds  are  specially  easily  infected  in  diabetics,  and 
gangrene  of  skin  flaps  after  amputation  is  relatively  common, 
especially  in  the  lower  limb.  To  avoid  an  acid  intoxication 
Naunyn  recommends  that  bicarbonate  of  soda  should  be 
administered  for  some  time  before  operation,  either  by 
the    mouth    or    intravenously. 

Results  of  operation. — -By  careful  aseptic  methods  much 
better  results  can  be  obtained  than  used  to  be  thought 
possible  ;  this  is  true  both  with  regard  to  operation  for 
ordinary  affections  in  diabetics  and  also  for  the  complications 
of  the  disease  itself.  According  to  Wolf's  tables,  which 
relate  only  to  diabetic  gangrene,  50  died  out  of  no  treated 
by  expectant  methods  (45  per  cent),  28  out  of  75  operated 
on  (37  per  cent)  ;  of  the  first,  13  recovered  completely  (12  per 
cent),  of  the  latter  three  times  as  many.  Korner's  statistics 
deal  with  diabetic  mastoiditis  ;  in  13  with  slight  diabetes  the 
wounds  healed  on  an  average  in  nine  weeks  ;  in  no  case  did 
the  operation  permanently  aggravate  the  diabetes.  In 
5  cases  where  the  disease  was  of  moderate  severity  the 
wounds  healed  completely,  and  no  aggravation  of  the 
diabetes  occurred.  Of  9  cases  of  severe  type  death 
followed  operation  in  4,  in  2  transitory  coma  occurred. 

Sternberg  collected  10  cases  of  diabetes  operated  on  in 
Gersuny's  clinic,  4  of  which  suffered  from  the  disease  in  a 
severe  form.  In  spite  of  the  fact  that  in  several  the  operation 
was  an  extensive  one  (cholecystectomy,  major  operation  on 
the  maxilla,  etc.),  death  resulted  from  the  operation  in  none, 
and   in   more   than   half   complete   recovery   followed.     Of 


476  INDICATIONS    FOR    OPERATION. 

75   cases  suffering  from  carbuncle,   5  died  from  sepsis  in 
spite   of  free   incisions. 

LITERATURE. 

Wolf.  Diabetische  Gangran  und  ilire  Behandlung.  Zusammen- 
fassendes  Referat.  Centralb.  f.  d.  Grenzgebiete  d.  Med.  u.  Chir. 
1901. 

TuFFiER.  Diabete  et  Neoplasma.  Arch.  Gener.  de  Med, 
Bd.  ii,  p.  318,  1888. 

Julius  Sternberg.  Ueber  Operationen  an  Diabetischen.  Wien. 
med.  Wochens.,  p.  213,  1903. 

Becker.  Die  Gefahren  der  Narkose  fiir  den  Diabetes.  Deut. 
med.  Wochens.,  p.   359,   1894. 

KoRNER.  Der  Einfluss  von  Operationen  auf  den  Verlauf  und 
Ausgang  des  Diabetes  MeUitus.  Mitteil.  a.  d.  Grenzgebiete  d.  Med. 
u.  Chir.     Bd.  xii,  H.  5. 

Lepine.  Intervention  Chirurgicale  chez  les  Diabetiques.  Lyon 
Medicale,  p.  234,  1900. 

Smith  and  Durham.  Glycosuria  and  Surgery.  Guy's  Hosp. 
Reports,  p.  335,  1893. 

Kausch.  Der  Diabetes  in  der  Chirurgie.  Centralb.  f.  Chir., 
p.  1 196,   1902. 

O.  Fellner.  Ueber  den  Diabetes  in  der  Chirurgie.  Wien. 
klin.  Wochens.,  No.   34,  1903. 

Naunyn.  Der  Diat)etes  MeUitus.  Nothnagel's  Handbuch  d. 
spez.  Pathol,  u.  Ther.     Wien.      1900. 

Demons  et  Begouin.  Note  sur  I'Amputation  dans  la  Gangrene 
Spontanee  des  Membres  chez  les  Diabetiques.  Bull,  et  Mem.  de  la 
Societe  de  Chir..  de  Paris.     T.  xxvii. 

W.  Kausch.  Beitrage  zum  Diabetes  in  der  Chirurgie.  Arch.  f. 
klin.  Chir.     Bd.  Ixxiv,  H.  4. 


477 


Appendix   III. 

THE     GENERAL     INFLUENCE     OF     OPERATIONS 
ON  THE  BODY. 

By  Dr.  Julius  Schnitzler. 

Operations  have  been  robbed  of  their  terrors  by  anaes- 
thesia, their  risks  by  asepsis,  and  of  the  greater  part  of  their 
uncertainties  by  improvements  in  technique  ;  yet  every 
operation  produces  a  certain  amount  of  psychic  and  somatic 
trauma,  which  must  be  taken  into  account  in  calculating 
its  therapeutic  effect.  It  is  necessary  to  enquire  into  this 
traumatic  influence  with  a  view  to  lessening  it  as  far  as 
possible  in  all  cases. 


POST-OPERATIYE    PSYCHIC    DISTURBANCES. 

Operation  has  a  psychic  influence  on  the  patient  from  the 
moment  when  it  is  suggested  to  him  by  his  medical  attendant, 
and  often  persists  for  a  considerable  time  after  recovery  is 
otherwise  complete.  The  degree  of  apprehension  varies 
very  much  according  to  the  temperament  of  the  patient, 
but  it  cannot  usually  be  exactly  foreseen  ;  some  phlegmatic 
individuals  are  stirred  up  into  a  state  of  terror  by  the  word 
operation,  whilst  others  of  a  neurotic  type  show  no  particular 
alarm,  and  agree  readily.  The  nature  of  the  affection  for 
which  operation  is  necessary,  the  pain,  and  the  degree  of 
inanition,  etc.,  play  a  considerable  part.  The  slight  psychic 
disturbance  which  is  inevitable  in  all  cases  is  usually  of 
short  duration,  but  occasionally  operation  is  followed  by 
permanent  mental  effects  ;    happily,  this  is  rare. 

Apart  from  the  occurrence  of  delirium  tremens  and 
inanition  delirium,  alcoholism,  advanced  age,  and  inanition 
are  sometimes  responsible  for  post-operative  psychoses. 
Operations  on  tlie  eye  are  specially  liable  to  be  followed  by 


478  GENERAL    INFLUENCE    OF    OPERATIONS 

menta  disturbance,  and  retention  for  a  long  time  in  a 
darkened  room  appears  to  favour  this  tendency. 

Both  in  the  female  and  the  male,  operations  on  the 
sexual  organs  sometimes  cause  mental  disturbance  ;  in 
the  male,  this  is  especially  notable  in  the  case  of  ablation 
of  the  testes  and  removal  of  the  prostate. 

The  prognosis  of  post-operative  psychoses  is  not  parti- 
cularly favourable  ;  a  fatal  result  is  not  uncommon  in  old 
men  and  patients  suffering  from  inanition  ;  and  apart  from 
the  danger  to  life  such  mental  disturbances  tend  to  persist. 
They  must  be  looked  upon  as  the  result  of  operative  shock 
on  predisposed  individuals,  and  are  therefore  quite  different 
in  etiology  from  the  toxic  delirium  which  sometimes  follows 
operation,  for  example,  the  delirium  of  iodoform  poisoning. 


SHOCK,   PNEUMOTHORAX. 

The  risk  from  the  onset  of  these  conditions  must  always  be 
discussed  in  forming  an  opinion  as  to  the  advisability  of  opera- 
tion ;  it  is  only  in  rare  instances  that  the  risk  from  mental 
disturbance  has  to  be  taken  into  consideration.  Operative 
shock  is  a  term  which  needs  definition  ;  it  is  now  used  not 
for  the  temporary  syncope  which  may  occur  in  the  course 
of  operations  done  without  anaesthetics,  but  for  the  state 
which  is  to  be  expected  after  all  operations  of  magnitude 
whose  chief  sign  is  a  more  or  less  pronounced  fall  in  blood 
pressure.  It  may  be  principally  due  in  any  given  case  to 
excessive  loss  of  blood,  or  to  long  exposure  and  chilling 
of  wound  surfaces,  or  to  the  handling  of  organs  which 
possess  special  nervous  sensibility.  In  degree  it  varies 
from  a  slight  transient  effect  passing  off  in  the  course  of  a 
short  time  to  a  condition  so  profound  that  no  remedies 
are  capable  of  warding  off  a  fatal  result.  In  every  case 
the  amount  of  shock  to  be  anticipated  should  be  estimated 
beforehand,  and  means  taken  to  obviate  its  onset. 

The  sudden  development  of  pneumothorax  in  the  course 
of  an  operation  on  the  chest  is  attended  by  risk  to  life. 
This  is  due,  not  to  the  fact  that  the  respiratory 'function  of 
the  lung  is  suspended,  but  to  the  sudden  change  of  pressure 
on  the  right  side  of  the  heart  and  the  sudden  deviation  of 
the  mediastinal  structures  towards  the  opposite  side.     In 


ON     THE     BODY.  479 

order  to  avoid  this  accident  in  the  course  of  operations  on 
the  lung  the  latter  may  be  fixed  to  the  pleura  in  such  a  way 
as  to  prevent  the  sudden  inrush  of  air.  Other  means, 
recently  suggested,  are  the  performance  of  such  operations 
in  a  chamber  in  which  the  air  pressure  is  kept  low  by  artificial 
means,  or  the  introduction  of  air  under  increased  pressure 
into  the  respiratory  channels.  These  methods  are  still  on 
their  trial.  Obviously  the  danger  from  pneumothorax  is 
greater  if  the  opposite  lung  is  not  functioning  normally. 
If  adhesions  exist  between  the  visceral  and  costal  pleura, 
pneumothorax  can  be  avoided ;  it  is,  therefore,  important 
to  examine  for  signs  of  such  adhesions,  and  in  cases  where 
they  do  not  exist  they  are  sometimes  produced  artificially 
by  sutures  ;  sutures  of  silk  soaked  in  turpentine  have  been 
employed  for  the  purpose.  There  is  comparatively  no 
risk  in  opening  the  pleural  cavity  when  the  lung  has  been 
already  compressed  by  effusion  ;  the  danger  varies  with  the 
suddenness  of  the  onset  of  the  increased  pressure,  and  when 
a  pneumothorax  is  inevitable  it  is  important  to  ensure 
that  the  entry  of  air  takes  place  slowly  and  steadily,  and 
to  cut  short  the  duration  of  the  pneumothorax  as  much  as 
possible  by  suturing  the  lung  to  the  pleural  wound. 


THE  EFFECTS  OF  OPENING  THE  ABDOMEN,  THE 
CRANIUM,  AND  THE  SPINAL  CANAL. 

Opening  the  abdomen  is  in  itself  free  from  danger  ; 
certain  complications  alone  call  for  remark.  If  a  large 
quantity  of  fluid  is  suddenly  withdrawn  from  the  abdomen, 
the  blood  pressure  may  be  suddenly  lowered  in  such  a 
manner  as  to  seriously  embarrass  the  heart.  When  the 
abdomen  is  greatly  distended,  laparotomy  is  followed  by 
herniation  of  the  intestinal  coils,  and  the  manipulations 
necessary  to  retain  and  replace  them  may  produce  severe 
shock  and  syncope.  The  ordinary  manipulations  of  the 
abdominal  organs  are,  generally  speaking,  well  borne, 
and  in  deep  anaesthesia  their  effect  on  the  pulse  is  minimal. 
In  incomplete  aucesthesia,  for  example  in  aucEsthesia  by 
the  local  infiltration  method,  the  effects  of  these  manipula- 
tions on  the  pulse  is  more  marked.  Pulling  on  the  mesenteric 
attachments  of  organs  in  particular  tends  to  produce  shock, 


48o  GENERAL    INFLUENCE    OF    OPERATIONS 

irregular  pulse,  and  a  fall  in  blood  pressure,  but  in  ordinary 
cases  there  is  no  actual  risk  to  the  patient.  More  danger 
is  associated  with  prolonged  exposure  of  the  abdominal 
organs ;  pneumonia  after  laparotomy  is  probably  due  to 
this  cause,  and  there  is  no  doubt  that  chill  produced  in  this 
way  is  responsible  for  shock  and  an  increased  susceptibility 
to  infection.  Means  must  be  taken  to  prevent  this  by 
protecting  any  exposed  organs  and  wound  surfaces,  not 
only  in  laparotomy  but  in  all  other  operations. 

Exposure  of  the  cranial  cavity  or  the  spinal  canal  is  not 
in  itself  associated  with  any  degree  of  risk  to  life.  The 
alterations  in  the  cerebral  circulation  which  follow  trephining 
are  not  of  so  much  importance  as  some  authors  have  thought. 
When  the  resulting  defect  in  the  skull  persists,  there  are 
special  dangers,  in  particular  hernia  cerebri  and  adhesions 
between  brain  and  meninges. 

When  the  intracranial  pressure  is  much  above  the  normal, 
as,  for  instance,  in  cases  of  cerebral  tumour,  the  sudden 
escape  of  cerebrospinal  fluid  may  give  rise  to  alarming 
symptoms,  respiratory  and  cardiac  failure,  and  even  sudden 
death.  Haemorrhage  may  also  occur  into  the  tumour,  an 
accident  which  has  also  been  observed  after  the  withdrawal 
of  fluid  by  lumbar  puncture.  It  is,  therefore,  necessary  to 
prevent  any  sudden  escape  of  the  fluid,  especially  when  it 
is  under  great  pressure.  The  brain,  however,  tolerates 
well  the  mechanical  irritation  of  the  ordinary  intracranial 
operations  ;  for  example,  the  prolonged  retraction  with 
a  spatula  which  is  necessary  during  resection  of  the  Gasserian 
ganglion. 

There  is  greater  risk  attached  to  the  exposure  of  the 
spinal  cord  ;  the  operation  is  more  severe,  and  therefore 
more  likely  to  be  followed  by  shock.  In  addition  to  this 
the  cord  itself  is  less  tolerant  of  pressure,  and  the  removal 
of  tumours  from  the  canal  is  more  likely  to  be  followed  by 
paralyses  and  other  phenomena  of  trauma  than  in  the  case 
of  the  brain.  As  has  been  already  said,  in  ordinary  cases 
opening  the  skull  is  free  from  any  considerable  risk,  and 
in  the  more  serious  cases  the  risk  does  not  compare  in 
gravity  with  the  affection  which  it  is  sought  to  relieve. 

In  cases  where  the  opening  in  the  skull  is  left  patent,  or 
cannot  be  closed,  epilepsy  is  particularly  liable  to  occur 
as  a  late  effect.      At  one  time   it    was  held   that  it  was 


ON     THE     BODY.  481 

inadvisable  to  close  such  defects,  and  they  were  left  open, 
with  the  idea  of  providing  against  the  evil  effects  of  varia- 
tions in  intracranial  pressure,  and  as  a  prophylactic  against 
epilepsy.  It  is  now  known  that  the  results  of  this  recom- 
mendation are  liable  to  be  the  opposite  to  those  desired, 
and  that,  in  addition  to  epilepsy,  mental  disturbances  are 
common.  Cerebral  hernia  has  already  been  mentioned ; 
it  occurs,  of  course,  only  in  cases  where  the  skull  defect  is 
not  closed,  and  may  lead  up  to  epileptiform  attacks  and 
other  disturbances  of  cerebral  function.  Skull  defects 
should,  therefore,  be  closed,  except  where  trephining  is 
done  simply  for  the  relief  of  intracranial  pressure,  as  in 
the  case  of  inoperable  brain  tumours. 


THE    EXTIRPATION    OF    GLANDULAR   ORGANS. 

Permanent  effects  follow  the  extirpation  of  the  whole, 
or  more  than  three-fourths,  of  the  thyroid  gland  ;  operative 
myxoedema  supervenes,  and  tetany  also  if  the  parathyroids 
are  removed  at  the  same  time.  About  a  third  of  the  gland 
should  always  be  left  ;  but  it  is,  of  course,  necessary  to 
break  this  rule  in  the  case  of  carcinoma.  In  the  latter 
case  the  onset  of  myxoedema  must  be  combated  either  by 
transplantation  or  administration  of  thyroid  substance. 
The  surgeon  is  hardly  likely  to  be  called  upon  to  remove 
any  considerable  portion  of  the  pancreas.  Certain  cases 
of  suppuration  and  necrosis  of  the  organ  have  shown  that 
the  loss  of  the  greater  part  of  the  pancreatic  tissue  is  liable 
to  be  followed  by  diabetes,  so  that  there  are  physiological 
as  well  as  technical  objections  to  its  removal. 

Reference  has  already  been  made  to  the  mental  disturb- 
ances which  may  follow  castration  ;  for  the  purpose  of 
iniluencing  prostatic  enlargement  the  operation  is  now 
practically  abandoned  ;  in  subjects  who  have  passed 
puberty  no  somatic  changes  of  importance  have  been  noted. 

The  removal  of  the  ovaries  from  women  who  have  reached 
puberty  produces  an  acute  menopause  which  is  liable  to 
be  associated  with  subjective  cardiac  symptoms,  and 
certain  mental  affections,  irritability  or  melancholia,  and 
even  mania ;  progressive  obesity  is  often  also  a  conse- 
quence.    The  nearer  a  woman  is  to  her  natural  menopause 

31 


482  GENERAL    INFLUENCE    OF    OPERATIONS 

the  less  liable  is  she  to  be  disturbed  by  extirpation  of  the 
ovaries.  The  operation  is  justified,  not  only  in  the  case  of 
malignant  disease,  but  in  certain  forms  of  inflammatory 
disease  also  (tuberculosis)  and  in  osteomalacia.  Proof  is 
still  wanting  that  it  is  a  justifiable  proceeding  in  inoperable 
breast  cancer. 

The  surgeon  need  never  hesitate  to  resect  liver  tissue  on 
physiological  grounds  ;  the  individual  is  capable  of  doing 
without  a  greater  proportion  of  his  liver  substance  than 
any  surgeon  would  find  it  possible  to  remove. 

In  the  case  of  the  bilateral  glandular  organs,  if  one  be 
removed,  the  other,  when  healthy,  is  capable  of  undertaking 
the  work  in  virtue  of  its  capacity  for  compensatory  hyper- 
trophy. This  is  particularly  exemplified  in  the  case  of  the 
kidneys.  Cases,  however,  are  met  with  from  time  to  time, 
where  after  nephrectomy  the  opposite  organ  not  only  refuses 
to  take  up  the  extra  work,  but  ceases  to  functionate 
altogether  ;  this  accident  is  usually  ascribed  to  reflex  action, 
and  the  condition  is  termed  reflex  anuria.  As  a  matter 
of  fact,  no  complete  explanation  has  yet  been  offered  ;  it  is 
analogous  to  the  anuria  which  sometimes  follows  the 
impaction  of  a  calculus  in  the  ureter  of  one  side.  Sometimes 
this  occurs  when  the  kidney  left  appears  to  be  entirely 
healthy,  but  it  is  far  more  liable  to  happen  if  the  function 
of  the  latter  is  compromised.  Hence  the  great  importance 
of  investigating  the  functional  efficiency  of  the  opposite 
organ  when  nephrectomy  appears  to  be  indicated.  Formerly 
it  was  held  that  if  the  amount  of  urea  excreted  was  less  than 
half  the  normal,  no  operation  on  the  kidney  of  any  kind  was 
justifiable.  To-day  the  examination  of  the  renal  function 
is  carried  further;  means  are  taken,  either  by  catheterization 
of  the  ureters  or  by  the  use  of  the  urine  separator,  to  obtain 
urine  from  each  kidney,  and  the  specimens  so  obtained 
are  examined  as  to  their  cryoscopic  point,  and  also  as  to 
the  amount  of  sugar  excreted  after  the  injection  of 
phloridzin.  The  cryoscopic  point  of  the  blood  is  also 
ascertained  ;  it  is  held  that  if  this  is  below  "56  the  prognosis 
of  nephrectomy  is  doubtful.  No  absolute  conclusion  can, 
however,  be  based  on  the  latter  method ;  nor  does  the 
discovery  that  the  kidney  which  it  is  proposed  to  leave  is 
of  normal  function  enable  one  to  predict  with  absolute 
certainty  that  it  will  respond  satisfactorily  to  the  extra 


ON     THE     BODY.  483 

demands  made  upon  it  by  nephrectomy.  These  methods 
of  examination  are,  however,  of  great  value,  and  should  be 
employed  in  all  cases.  Too  much  weight  must  not  be 
given  to  unfavourable  results  from  these  methods  when 
the  affection  of  the  kidney  which  appears  to  call  for 
nephrectomy  is  one  which  menaces  life  ;  for  example,  in 
advanced  suppurative  nephritis,  the  removal  of  the  affected 
kidney  may  be  the  patient's  only  chance  of  regaining  health. 
Extirpation  of  the  spleen  is  well  borne  as  far  as  functional 
conditions  are  concerned  ;  this  has  been  proved  by  many 
operative  experiences.  After  splenectomy  the  blood  shows 
no   permanent   alteration. 

ANESTHETICS. 

The  question  of  the  influence  of  an  anaesthetic  on  a 
patient  is  always  one  of  importance. 

-Local  AncBsthetics. — In  using  cocaine  in  strong  solutions  its 
toxicity  must  be  remembered ;  not  more  than  5-6  centigrams 
ought  to  be  injected,  and  half  this  amount  in  the  region  of 
the  head.  As  far  as  possible  its  absorption  should  be  pre- 
vented by  placing  some  form  of  tourniquet  above  the  seat  of 
injection.  The  injection  of  the  stronger  solutions  (several 
grams  per  cent)  into  the  urethra  and  bladder  is  undoubtedly 
risky.  Reclus,  it  is  true,  considers  the  drug  harmless  after  a 
large  personal  experience  of  its  use,  but  the  practitioner  will 
do  well  to  remember  that  serious  symptoms  of  intoxication  do 
occur  in  a  certain  number  of  cases,  and  that  special  suscepti- 
bility to  its  action  is  by  no  means  rare.  In  these  cases, 
vertigo,  nausea,  vomiting,  respiratory  spasm,  and  loss  of 
consciousness  may  supervene.  If  they  occur  they  must 
be  met  by  artificial  respiration  and  amyl  nitrite,  and  later 
by  the  administration  of  coffee  and  brandy. 

It  is  best  to  avoid  strong  solutions  of  the  drug  altogether 
for  subcutaneous  injection,  and  either  employ  one  of  the 
substitutes,  eucaine  or  tropacocaine,  which  are  almost  if  not 
quite  non-toxic,  or  to  use  it  in  the  dilute  solutions  (1-2  : 
1000)  recommended  by  Schleich.  The  solutions  of  Schleich 
are  in  normal  salt  solution,  with  the  addition  of  small 
quantities  of  morphine.  Although  it  is  possible  by  the 
use  of  these  solutions  to  render  painless  even  operations 
of   considerable    magnitude,    yet    most    surgeons    prefer   a 


484  GENERAL    INFLUENCE    OF    OPERATIONS 

general  aneesthetic  under  these  circumstances,  to  avoid 
psychic  shock  and  the  being  dependent  on  the  intelhgence 
and  character  of  the  patient. 

Of  the  weakest  solutions  of  Schleich  as  much  as  50  ccm. 
may  be  used  without  risk  of  intoxication  ;  although  such 
an  amount  contains  5  centigrams  of  cocaine,  in  this  weak 
dilution  the  toxic  effect  is  much  less  than  when  injected  in 
concentrated  solution.  The  addition  of  adrenalin,  recently 
recommended,  ensures  a  more  intense  and  a  longer  anaes- 
thesia ;  the  small  amounts  which  have  been  employed 
have  no  general  effect,  but  occasionally  some  local  necrosis 
has  been  caused.  The  method  of  spinal  anaesthetization, 
introduced  b}^  Bier,  has  several  disadvantages.  It  is 
uncertain,  it  can  only  be  used  for  operations  on  the  lower 
part  of  the  body,  and  it  has  in  several  cases  caused  death. 
It  has  yet  to  be  shown  whether  toxic  effects  can  be  obviated 
by  substituting  tropacocaine  for  cocaine.  In  a  certain 
number  of  cases  the  latter  causes  fever,  malaise,  nausea, 
vomiting  and  intense  headache,  and  has  no  advantage 
over  a  general  anc^sthetic  in  this  respect. 

General  Ancesthetics.  —  Of  the  general  anaesthetics, 
reference  will  be  made  here  only  to  chloroform  and  ether. 
The  other  substances,  bromethyl,  ethyl  chloride,  pental. 
etc.,  are  of  less  practical  importance,  and  experience  has 
shown  that  they  are  no  safer. 

In  the  case  of  chloroform,  risk  of  paralyzing  the  respira- 
tory centre  is  to  be  avoided  by  regulating  the  dose.  This 
paralysis  must  not  be  confused  with  the  spasm  of  the 
respiratory  muscles  which  occurs  in  the  early  stages  of 
narcosis.  If  respiratory  arrest  takes  place,  recovery  will 
follow  withdrawal  of  the  anaesthetic  and  artificial  respiration 
if  the  pulse  remains  good.  With  regard  to  the  effect  of 
chloroform  on  the  heart,  it  has  been  shown  that  it  is 
particularly  in  abnormal  conditions  of  the  heart  muscle 
that  danger  is  to  be  anticipated,  whilst  patients  with  valvu- 
lar disease  which  is  well  compensated  stand  the  anaesthetic 
well.  Death  from  heart  failure  during  or  immediately 
following  chloroform  anaesthesia  takes  place  relatively 
frequently  in  patients  with  the  so-called  status  thymicus, 
and,  according  to  the  recent  researches  of  Wiesel,  this  is 
due  to  the  deficiency  of  chromafiine  substance,  which  has 
a  regulating  effect  on  the  blood  pressure.     Unfortunately, 


ON     THE     BODY.  485 

the  diagnosis  of  this  dangerous  state  is  not  easy  ;  it  is 
shown  by  dullness  over  the  manubrium  sterni,  slight  hyper- 
trophy of  the  spleen,  a  goitre  of  small  dimensions,  and, 
most  important  of  all,  hypertrophy  of  the  tongue  follicles. 
Patients  with  this  condition  tolerate  badly  surgical  inter- 
vention of  all  kinds ;  therefore,  only  absolutely  necessary 
operations  should  be  performed  on  them,  and  either  under 
ether  or  local  anaesthesia. 

Pulmonary  disease  is  no  contra-indication  to  chloroform, 
unless  it  is  acute,  or,  if  chronic,  of  a  very  extensive  type. 

Slight  diabetes  does  not  contra-indicate  chloroform 
narcosis,  but  in  the  case  of  severe  diabetes,  coma  is  liable 
to  follow  anaesthesia,  especially  if  the  urine  contains  acetone 
or  acetic  acid.  Patients  who  are  suffering  from  septicgemia, 
or  some  acute  febrile  disorder,  only  require  small  doses 
of  anesthetic  ;  with  larger  doses  there  is  grave  danger  of 
heart  failure.  Great  care  is  necessary  in  administering 
chloroform  in  cases  of  patients  with  extreme  meteorism  ; 
the  movements  of  the  heart  are  embarrassed  by  the  elevation 
of  the  diaphragm.  There  is  risk  also  of  aspiration  of  vomited 
matters,  but  this  can  usually  be  avoided  by  previously 
washing  out  the  stomach.  In  every  case  the  degree  of 
anaesthesia  necessary  must  be  specially  considered,  and 
the  anaesthetic  not  pushed  beyond  this  ;  it  should  be 
remembered  that  large  doses  of  chloroform  may  cause 
serious  organic  lesions  ;  albuminuria  and  jaundice  are 
sometimes  directly  attributable  to  its  toxic  effect,  and 
it  sometimes  also  has  a  distinct  deleterious  action  on  the 
myocardium. 

Ether  is  a  distinctly  less  harmful  anaesthetic  than  chloro- 
form. In  the  dose  which  is  necessary  for  anaesthesia  it 
has  a  distinct  stimulating  effect  on  the  heart,  and  it  has  no 
such  marked  tendency  to  paralyse  the  respiratory  centre 
as  chloroform.  Its  effect  on  the  respiratory  passages  is, 
however,  greater,  and  in  a  certain  number  of  cases  it  is 
responsible  for  pneumonia  and  bronchitis.  This  effect  may 
be  for  the  most  part  avoided  by  administering  the  anaesthetic 
in  proper  dilution  and  gradually.  It  does  not  appear  to 
have  any  harmful  influence  on  the  kidney  or  the  liver. 

Ether  is,  therefore,  preferable  to  chloroform  for  patients 
with  cardiac  or  renal  disease  ;  it  is  contra-indicated  in 
emphysema  and  bronchitis. 


486  GENERAL    INFLUENCE    OF    OPERATIONS 

For  operations  of  short  duration,  such  as  tooth  extraction 
and  simple  incisions,  it  is  only  necessary  to  use  small 
amounts  of  ether  to  produce  a  condition  of  intoxication 
rather  than  narcosis,  in  which  there  is  analgesia  rather 
than  actual  anaesthesia. 

It  is  often  the  most  rational  plan  to  use  a  mixture  of 
chloroform  and  ether  ;  and  the  mixture  of  Billroth  which 
contains  alcohol  also  is  one  very  largely  in  use. 

Morphine  is  an  assistant  to  narcosis  which  is  not  so 
much  used  as  it  deserves.  I  advocate  a  dose  of  1-2  centi- 
grams about  half  an  hour  before  the  general  anaesthetic. 
It  is  contra-indicated  only  in  children  and  in  patients 
suffering  from  septicaemia.  Less  of  the  general  anaesthetic 
is  required  if  this  be  given  beforehand  ;  in  alcoholics  in 
particular  it  is  often  hardly  possible  to  obtain  satisfactory 
narcosis   without   it. 

Certain  effects  of  narcotics  on  already  existing  affections 
must  be  noted.  In  certain  states  of  intoxication  and  infec- 
tion chloroform  appears  to  aggravate  the  condition,  and  in 
particular  its  effect  on  the  state  of  the  heart.  This  is 
sometimes  seen  in  the  case  of  operations  on  septic  abdominal 
foci ;  even  though  the  operation  itself  may  be  slight,  the 
symptoms,  and  particularly  the  heart  symptoms,  are  in 
certain  cases  markedly  augmented  after  anaesthesia.  In 
patients  suffering  from  such  intoxications  and  infections, 
ether  is  certainly  to  be  preferred  to  chloroform. 


THE    INFLUENCE    OF    CERTAIN    DISEASES   ON    THE 
INDICATIONS    FOR   OPERATION. 

The  indications  for  operation  in  the  case  of  patients 
suffering  from  some  complicating  disease  vary  according 
to  the  seriousness  of  the  condition  which  the  operation  is 
designed  to  relieve.  On  the  one  hand,  affections  which 
imminently  threaten  life  will  be  operated  on  whatever 
associated  disease  may  be  present,  unless  the  patient  is 
moribund ;  and,  on  the  other  hand,  one  will  hesitate  to 
operate  for  the  relief  of  some  cosmetic  disability  if  the  patient 
has    some    affection    which    increases    the    risk.     Between 


ON     THE     BODY.  487 

these  two  extremes  there  are  a  whole  series  of  conditions, 
each  of  which  must  be  judged  on  its  merits. 

It  has  already  been  remarked  that  well-compensated 
Heart  Disease  does  not  contra-indicate  operation  when  this 
is  called  for  by  some  disability  of  importance.  Intervention 
in  the  presence  of  defective  compensation  is  always  risky, 
but  is  not  contra-indicated  when  life  is  threatened,  and, 
in  particular,  in  the  case  of  operations  undertaken  to  relieve 
the  circulatory  embarrassment,  evacuation  of  ascitic  or 
pleuritic  effusion,  the  removal  of  large  abdominal  tumours, 
and  the  like.  Sometimes,  when  valvular  disease  is  well 
compensated,  a  troublesome  tachycardia  follows  operation, 
but  this  usually  yields  to  the  application  of  an  ice-bag  and 
to  drugs,  such  as  digitalis  and  strophanthus. 

In  Arteriosclerosis  there  is  risk  of  cerebral  haemorrhage, 
and  I  have  seen  this  fatal  in  two  cases  ;  the  one  a  case 
of  carcinoma  of  the  breast,  the  other  a  myoma  uteri.  In 
the  latter  case  the  operation  was  done  with  the  pelvis 
elevated,  a  position  to  be  avoided  under  such  circumstances. 
In  the  presence  of  serious  disease  of  heart  or  vessels,  each 
case  must  be  judged  separately.  I  consider  that  a  patient 
who  has  a  scirrhous  cancer  of  the  breast  or  a  squamous 
carcinoma  should  be  left  unoperated  on  if  there  is  at  the 
same  time  a  serious  cardiac  lesion ;  both  are  slow-growing 
cancers,  and  the  patient  will  probably  live  longer  if  left 
alone.  On  the  other  hand,  in  such  a  condition  as  chronic 
intestinal  stenosis  in  a  patient  with  heart  disease,  the 
stenosis  should  be  operated  on,  the  danger  from  this  being 
greater  than  that  from  the  cardiac  affection. 

In  patients  suffering  from  Tuberculous  Disease  it  is  well 
known  that  operative  interference  on  local  tuberculous 
foci  may  be  occasionally  followed  by  dissemination.  It  is 
impossible  to  foresee  such  a  deplorable  consequence,  and 
the  great  majority  of  such  operations  are  well  borne.  In 
the  case  of  patients  with  pulmonary  tuberculosis  the  effect 
of  the  disease  on  operative  procedures  elsewhere  depends 
upon  its  stage.  In  the  presence  of  florid  phthisis,  radical 
procedures  not  involving  a  long  convalescence  are  preferable 
to  the  more  conservative  ;  but  when  the  pulmonary  disease 
is  not  active  the  latter  measures  are  more  justiliable.  Ether 
as  an  amesthetic  is  generally  to  be  avoided  for  phthisical 
subjects.     Circumscribed    tuberculous  foci  of  the  intestine 


488     GENERAL    INFLUENCE    OF    OPERATIONS 

which  are  interfering  with  nutrition  should  be  operated  on, 
even  when  there  is  pulmonary  disease,  provided  that  the 
intestinal  lesions  are  not  too  advanced  ;  this  particularly 
applies  to  stenosis  and  abscess. 

In  the  case  of  patients  suffering  from  Bright' s  Disease 
it  is  well  to  follow  the  rule  that  when  the  condition  for 
which  operation  is  required  is  more  menacing  to  life  than 
the  nephritis,  operation  should  be  undertaken  ;  when  this 
is  not  £0  it  is  well  to  abstain.  Conditions  such  as  rapidly 
growing  malignant  disease,  intestinal  stenosis,  appendicitis, 
and  such  like,  will  be  operated  on  in  spite  of  nephritis  ;  while 
benign  tumours,  malformations,  and  other  conditions  of 
this  type  will  be  left  alone.  Chloroform  should  never  be 
given  to  a  patient  with  Bright's  disease. 

In  the  case  of  patients  with  Leuccsmia  or  P seudoleuccsmia 
only  operations  whose  indication  is  vital  should  be  under- 
taken. The  risks  are,  first,  post-operative  haemorrhage, 
and  secondly,  delay  in  healing  of  wounds.  Extirpation 
of  the  spleen  or  of  pseudoleucsemic  glands  are  irrational 
procedures,  and*should  not  be  practised. 

It  is  sometimes  necessary  to  operate  on  HcEmophilics, 
and  cases  are  on  record  where  the  arrest  of  haemorrhage 
has  not  presented  the  difficulties  anticipated.  No  operation 
will,  however,  be  done  that  is  not  absolutely  of  vital 
importance.  Calcium  chloride  should  be  administered 
beforehand  in  order  to  aid  local  haemostasis. 

Operations  have  many  times  been  performed  on  patients 
suffering  from  chronic  diseases  of  the  spinal  cord  :  tabes, 
syringomyelia,  etc.  In  addition  to  the  cases  operated  on 
in  error  (e.g.,  laparotomy  for  gastric  crises  diagnosed  as 
gastric  ulcer)  a  considerable  number  of  cases  of  nervous 
arthropathy  have  been  operated  on.  The  results  are  not 
imiform,  but  it  appears  that  if  strict  asepsis  is  practised 
the  wounds  heal  quite  satisfactorily. 


IMPORTANT  COMPLICATIONS  AFTER  OPERATION. 

Pneumonia  is  sometimes  embolic  (particularly  in  opera- 
tions on  the  intestines),  sometimes  hypostatic,  sometimes 
due  to  aspiration  of  vomited  matter  into  the  air  passages. 


ON     THE     BODY.  489 

and  sometimes  induced  by  chill  during  the  course  of  the 
operation.  Except  for  the  embolic  form  the  complication 
is  one  that  can  be  avoided  by  due  precautions.  The  treat- 
ment is  the  same  as  in  pneumonia  of  ordinary  type  :  sup- 
port the  heart,  give  stimulants,  then  expectorants.  Fever 
and  rapid  respiration  after  operation  will  always  indicate 
careful  examination  of  the  chest. 

Among  intestinal  complications  attention  has  recently 
been  drawn  to  the  occasional  occurrence  of  obstinate  and 
sometimes  fatal  Diarrhoea  after  gastro-enterostomy,  but 
this  is  very  rare.  Peptic  Ulcer  is  another  complication 
which  may  follow  this  operation,  but  it  also  is  quite 
uncommon.  The  possibility  of  its  occurrence  should  be 
borne  in  mind  especially  in  cases  where  hyperchlorhydria 
is  demonstrated  before  operation.  In  such  cases  alkalies 
should  be  given  after  operation  and  the  diet  regulated  with 
much  care. 

Stomach  Paralysis  is  an  accident  which  may  follow 
anaesthesia  for  operations  of  any  kind.  The  signs  are 
uncontrollable  vomiting,  at  first  of  bilious  matter  and  later 
of  blood,  and  marked  distension  of  the  stomach.  Some- 
times the  condition  has  a  mechanical  cause,  such  as  kinking 
at  the  duodenojejunal  junction,  but  in  most  cases  it  is  a 
condition  of  primary  paralysis  and  dilatation.  In  marked 
cases  death  is  not  unusual. 

Intestinal  Paralysis  occurs  after  abdominal  operations. 
When  at  all  marked,  peritonitis  will  always  be  suspected. 
Probably  most  of  the  mild  cases  are  examples  of  slight 
peritonitis,  though  direct  trauma  by  handling,  etc.,  is  no 
doubt  also  sometimes  responsible.  If  a  purgative  and 
enema  do  not  relieve  the  symptoms  within  the  course  of 
twenty-four  hours  or  so,  there  is  probably  either  peritonitis 
or  some  mechanical  obstruction  of  the  bowel. 

The  Pulse  usually  returns  to  normal  during  the  twenty- 
four  hours  which  follow  the  operation  ;  in  some  patients 
about  the  age  of  puberty,  and  in  some  women  and  infants, 
there  is  tachycardia  for  several  days  later  without  any 
definite  cause. 

The  Temperature  is  alwa^^s  carefully  watched  after  opera- 
tion. A  normal  temperature  does  not  of  course  mean  that 
all  is  well,  nor  fever  that  there  is  some  serious  complication. 
The  temperature  is  always  to  be  compared  with  the  other 


490  GENERAL    INFLUENCE    OF    OPERATIONS. 

symptoms,  and  particularly  with  the  pulse.  A  rising 
temperature  and  a  rapid  pulse  usually  mean  some  inflam- 
matory complication.  Special  attention  should  be  given 
to  the  comparison  of  temperature  and  pulse,  particularly 
after  abdominal  operations  ;  while  a  rise  of  temperature 
and  pulse  together  point  to  infection,  in  the  worst  cases 
the  temperature  is  often  normal  or  subnormal  and  the  pulse 
rapid.  It  is  when  the  pulse  and  temperature  part  company 
that  the  most  serious  complications  are  to  be  feared. 


491 


INDEX. 


Abdomen,  Effects  of  Opening  .  . 
Abortion,  Indications  for  Procur- 
ing 

—  in  Osteomalacia 
Abscess,  Appendicular 

—  Cerebellar 

—  Extradural 

—  Frontal 

—  Intraperitoneal 

—  of  the  Brain  . . 

— •  Kidney 

Liver    .  .  .  .         255, 

Lung    . . 

Spleen 

—  —  —  Sternum 

—  —  —  Temporal  Lobe 

—  in  Tubercular  Spondylitis    .  . 

—  Perinephritic  . . 

—  Retropharyngeal      46,  47,  94, 

—  Subphrenic      .  .  177,  255, 
Actinomycosis  of  the  Intestine 

Lung    . . 

Adhesions,  Peritoneal 
Albuminuria,  in  Pregnancy 
Alexia,  in  Cerebral  Tumour 
Anal  Fissure 
Anaemia,  in  Pregnancy 
Anaesthesia,  Local 
Anesthetics,  General 
Anasarca   . . 
Aneurysm 

Aortic  . . 

—  Intracranial    . . 

—  of  the  Renal  Arteries 
Angina,  Ludwig's 
Angioneurotic  Haematuria 
Angular  Curvature 
Anuria  in  Renal  Calculus 
Anus,  Artificial,  in  Dilatation  of 

Colon 

—  —  —  Intestinal  Cancer 
Ulcers 

—  —  —  —  Stenosis 

—  —  —  Mesenteric  Embolism 

—  —  —  Membranous   Enteritis 

—  —  —  Proctitis 

—  —  —  Rectal  Cancer 
Aortic  Aneurysm . . 

Aphasia  in  Cerebral  Haemorrhage 

—  Motor  . . 

—  Optic 

—  Sensory 


='AGE 

PAGE 

479 

Appendicitis 

•  .        254 

—  in  Pregnancy  .  . 

468,      264 

459 

Arteriosclerosis  and  Operation  .  .      487 

455 

Arthritis  Deformans 

•  •        452 

257 

Arthrodesis  in  Poliomyelitis      .  .        59 

16 

Arthropathy,  Nervous 

•  •      449 

17 

Artificial  Anus  (see  Anus) 

16 

Ascites 

..      298 

272 

Ataxia,  Cerebellar 

6 

15 

—  in  Frontal  Lobe  Abscess      . .        16 

430 

Aura,  Epileptic    .  . 

..        28 

338 

105 

364 

Banti's  Disease  . . 

••      357 

134 

Bile-ducts,  Diseases  of 

•  •      307 

16 

•  Obstruction  of 

■  •      310 

44 

Biliary  Calculus   . . 

•  ■      307 

435 

—  Colic     . . 

. .      308 

161 

Bladder,  Inflammation  c 

)f  the   .  .      441 

301 

—  Tuberculosis  of  the  . 

424,  444 

211 

Bleeding  (see  Venesectio 

n) 

III 

Blood,  Diseases  of,  in  Pregnancy     463 

284 

—  Iodine  Reaction  in 

.  •      259 

465 

Blood-vessels,  Diseases 

of          .  .      141 

5 

—  Paralysis  of    . . 

50 

221 

—  in  Graves'  Disease 

81 

463 

Bones,  Diseases  of 

•  •      449 

483 

Brachial   Neuralgia 

..        67 

484 

Brain,  Abscess  of  the 

15 

148 

—  Cysticercus  of  the 

8 

143 

—  Diseases  of  the 

I 

143 

—  Gumma  of  the 

. .  I,  II 

8 

—  Glioma  of  the . . 

I 

410 

—  Hernia  of  the . . 

.  .      481 

161 

—  Hydatid  Cyst  of  the 

7 

387 

—  Tuberculosis  of  the 

. .  I,   II 

44 

—  Tumours  of  the 

I 

394 

Brasdor's  Operation 

146 

Bright's  Disease  .  . 

■•      383 

251 

—  —  and  Operation 

. .      488 

245 

Bronchi,  Diseases  of 

99 

214 

Bronchiectasis 

99 

230 
218 

Bronchitis,  Putrid 

..      103 

216 
223 

Cachexia,  in  Pregnancy 

. .      464 

248 

Calculus,    Biliary.. 

•  •      307 

143 

—  Pancreatic 

•■      373 

33 

—  Renal   . . 

..      389 

5 

—  Ureteral 

■  ■      394 

16 

Carcinoma  of  the  Cardia 

.  .      184 

5 

Gall-bladder 

..      325 

492 


INDEX. 


PAGE 
409 

377 

295 
193 

246 
183 

439 
487 
455 
473 


Carcinoma  of  the  Intestine 

—  —  —  Kidney 

—  - —  —  Liver    .  . 

—  —  —  CEsophagus 

—  —  —  Pancreas 
—  —  Peritoneum 

—  —  —   Pylorus  .  .         18 
—   Rectum 

—  —  —  Stomach 
Cardiac  Disease  in  Pregnancy  .  . 

—  —  and  Operation 
Castration,  for  Osteomalacia 
Cataract,  Diabetic 
Cauda  Equina,  Lesions  of  51, 
Cellulitis,    Retropharyngeal 
Cerebellum,  Abscess  of  the 

—  Tumours  of  the 
Cerebral  Abscess .  . 

—  Diplegia 

—  Hemorrhage  .  . 

—  Palsy,  in  Children 

—  Puncture  .  .  12, 

—  Tumour 

Cerebrospinal  Meningitis 
Cervical  Muscles,  Spasm  of 

—  Rib 

Chloroform  Anaesthesia  . . 
Chlorosis,  Venesection  for 
Cholecystectomy 

Cholecystenterostomy     . .  314, 

Cholecystitis,  Acute         .  .  310, 

Cholecystostomy,    in    Pancreatic 

Tumour.  . 

—  in  Gall-stones 
Choledochotomy  .  . 
Cholelithiasis 

—  in   Pregnancy . . 
Chorea  Gravidarum 
Choroid,  Tubercle  of  the 
Circulatory  Embarrassment, Vene- 
section for 

Cirrhosis  of  the  Liver,  Atrophic 
Cocaine,  Toxicity  of 
Caecotomy.  . 
Colic,  Biliary 

—  Intestinal         . .  . .         227, 

—  Renal  385,  388,  391,  400,  402,  416, 

420,  425,  431 
Colitis,  Mucous     .  . 

—  Ulcerative 

Colon,  Congenital  Dilatation  of 
Colostomy 

Common  Bile-duct  Obstruction 
Complications  after  Operation. 
Contusions,  Renal  . .  .  .      399 

Conus  Terminalis,  Lesions  of      .  .        51 
Convulsions  in  Cerebral  Abscess       16 

—  —  —  Haemorrhage  . .  .  .        33 

—  —  —  Tumour  . .  .  .  4 

—  —  Epilepsy    . .  . .  . .        28 

—  —  Hydrocephalus     .  .  .  .        24 

—  —  Meningitis  .  .  .  .        37 

—  —  Tubercular  Meningitis     .  .        35 
Craniotabes  . .  .  .  .  .        25 

Cranium,  Effects  of  Opening     .  .      479 


P.\GE 

92 

482 
311 
413 
414 


161 

16 

6 

15 

32 

33 

31 

6,  38 

I 

37 

74 

67 

484 

155 

314 

378 

320 

379 
314 
314 
307 
469 
470 
35 

154 
342 
483 
214 
308 
237 


213 
250 
248 


Croup 

Cryoscopy  in  Renal  Disease 

422,  426, 
Cystic  Duct,  Obstruction  of 

—  Kidney  ■  . . 

—  Liver    .  . 

Cysticercus  of  the  Brain . 
Cystitis       . .  .  .  . .  . .      441 

Cystotomy  . .  .  .         442,  446 

Cyst,  Hydatid      7,   no,  333,  353,  416 

—  Omental  and  Mesenteric      . .      295 

—  Splenic  . .  . .  . .      354 

—  Pancreatic       . .  . .  . .      374 


Delirium  in  Cerebral  Abscess  .  .  16 

Dermoid  Cyst,  Mediastinal  ..  135 

Diabetes  and  Ana?sthesia  . .  474 

Diabetics,  Operations  on  . .  473 

Diarrhoea,  Post-operative  . .  489 

Diffuse  Peritonitis            .  .  .  .  275 

Dilatation,     Congenital,     of  the 

Colon      .  .           . .          .  .  .  .  250 

—  of  the  CEsophagus      .  .  . .  167 

—  —  —  Stomach           .  .  .  .  192 
Diphtheria             .  .           . .  .  .  92 

—  in   Pregnancy . .           . .  .  .  464 

Diplegia,  Cerebral            . .  .  .  32 

Di\'erticulum  of  the  CEsophagus  168 

Dropsy       .  .           . .           .  .  .  .  148 

Ductus  Choledochus,   Occlusion  310 

—  Cysticus,  Occlusion   ..  ..  311 
Duodenal  Stenosis            .  .  . .  204 

—  Ulcer    . .          . .          . .  . .  201 

Dysentery,  Chronic         . .  . .  213 


Eclampsia,  Induction  of  Labour 

in             .  .           .  .           .  .  . .  466 

—  Venesection  for  .  .  . .  154 
Ectasis  of  the  Stomach  .  .  . .  192 
Embolism,  Mesenteric  .  .  . .  217 
Empyema  of  the  Gall-bladder  311,  320 

—  —  —  Pleura              ..  117,  301 
Enteric  Fever  in  Pregnancy  . .  464 
Enteritis,  Membranous   .  .  . .  215 
Entero-anastomosis    for    Actino- 
mycosis             . .           .  .  . .  212 

—  —  Cancer        .  .          .  .  . .  245 

—  —  Obstruction           .  .  . .  238 

—  —  Stenosis      .  .           .  .  . .  230 

—  —  Tuberculosis          .  .  .  .  209 

—  —  Ulceration  .  .  . .  214 
Enterostomy    in     Intestinal 

Obstruction       . .           . .  . .  238 

Enuresis,  Nocturnal         .  .  . .  443 

Epigastric  Hernia             .  .  . .  180 

Epilepsy    . .           .  .           .  .  .  .  27 

—  after  Trephining         .  .  . .  480 

—  during   Pregnancy      .  ,  .  .  470 

—  in  Cerebral  Palsy       . .  .  .  31 

—  —  —  Abscess             . .  .  .  16 

—  —  —  Tumour            .  .  .  .  5 

—  Jacksonian  ..  .  .  4,  9,  16,  28 
Erysipelas  during  Pregnancy  .  .  464 


INDEX. 


493 


Ether  Anaesthesia 
Exophthalmic  Goitre 
Eyelids,    CEdema    of,    in    Sinus 
Thrombosis 


^85 

8i 


Fat  Necrosis 

•      369 

Facial  Spasm 

73 

Fevers,   Infectious,  during  Preg- 

nancy    . . 

•      464 

Fifth  Cranial  Nerve,  Neuralgia 

of       63 

Fistula  of  Gall-bladder  . . 

■      378 

Flanks,  Meteorism  of  the 

220 

Flexure,  Volvulus  of  the  Sigmoid     233 

Floating    Kidney . . 

.      402 

—  Spleen 

•      359 

Foot,  Perforating  Ulcer  of 

75 

Foreign  Bodies  in  the  Lungs 

102 

Qisophagus 

•      133 

Stomach    . . 

190 

Frontal  Lobe,  Abscess  of 

16 

Tumours  of 

5 

Fusiform  Dilatation  of  OEsophag 

us    167 

GALL-bladder,  Carcinoma  of 

•      325 

— •  Diseases  of     . . 

•      307 

—  Empyema  of  .  . 

■      320 

—  Extirpation  of 

•      314 

—  Fistula  of 

•      378 

—  Hydrops  of     . . 

•      318 

—  Perforation  of 

■      311 

Gall-stones 

•      307 

Gall-stone,    Obstruction    by 

204,  227,  2 

30,  322 

Galvanopuncture  in  Aneurysm 

147 

Gangrene  of  the  Lung     .  . 

20,   102 

Gasserian  Ganglion,  Removal 

of       64 

Gastralgia,  Hysterical     .  . 

.      180 

Gastric  Dilatation 

.      192 

—  Ulcer 

•      177 

Perforating              178,   2 

77,  301 

Gastro-enterostomy  in  Hour-gla 

ss 

Stomach 

•     195 

Gastro-enterostomy  in  Duoden 

al 

Stenosis 

■      205 

Gastric  Cancer     . . 

.      187 

Ulcer    . . 

.      182 

Gastrostomy    in    CEsophageal 

Stricture 

.      172 

—  in  Stomach  Cancer    . . 

.■    187 

Gelatin  Injections  in  Aneurysn 

1       146 

Glandular  Organs,  Extirpation 

of     481 

Glaucoma 

.        64 

Glioma  of  the  Brain 

I 

Goitre,  Exophthalmic     . . 

81 

—  Intrathoracic 

•      135 

Graves'  Disease   . . 

81 

Gumma  of  the  Brain 

.  I,   II 

Liver    . . 

•      331 

Meninges 

I 

H/KMATE.VIESIS         .  .               .  .             I 

78,  201 

—  during   Pregnancy 

•      467 

Haematuria  in  Bladder  Tubercle 

—  Angioneurotic 

—  in  Hydronephrosis 

—  —   Nephralgia 

—  —   Pregnancy 

—  —  Pyelitis 

—  —  Renal  Calculus 

—  —  —  Contusions 

—  —  —  Tuberculosis 

—  —  —  Tumours 
Hemophilia  and  Pregnane}^ 
Haemophilics,  Operations  on 
Hemorrhage,  Cerebral    . . 

—  Intra-abdominal 
Hemorrhoids 
Hair-ball  in  Stomach 
Heart,  Diseases  of 

Heart  Disease  and  Chloroform 

—  —  —  Operation 

—  —  —  Pregnancy 

Heat  Stroke,  Venesection  for 
Hemianopsia  in  Cerebral  Abscess 

—  —  —  Tumour 
Hemiathetosis 
Hemichorea 
Hemiparesis  in  Cerebral  Abscess 
Hemiplegia  in  Cerebral  Abscess 

—  —  —  Haemorrhage  .  . 

—  —  —  Palsy    .  . 

—  —  —  Tumour 
Hepatic  Duct,  Drainage  of 
Hernia,  Epigastric 

—  and  Intestinal  Stricture 

—  of  Brain 
Herpes  Zoster 
Hour-glass  Stomach 
Hydatid  Cyst  of  the  Brain 

—  —  —  —  Kidney 

—  —  —  —  Liver 

—  —  —  —  Lung 

—  —  —  —  Spleen 

—  —  Muitilocular 
H^'drarthrosis,    Intermittent 
Hydrocephalus 

—  Acquired 

—  Acute   .  . 

—  and  Cerebral  Tumour 

—  Rupture  of 
Hydronephrosis    .  . 
Hydrops  Anasarca 

—  of  the  Gall-bladder    .  . 
Hydrothorax 
Hyperemesis  Gravidarum 
Hypernephroma  . . 
Hyperplasia  of  the  Spleen 
Hypertrophy,  Congenital  Pyloric 

—  of  the  Tonsils.  . 
Hysteria  during  Pregnancy 
Hysterical  Gastralgia 


PAGE 

445 
387 
420 
388 
467 
430 
391 
400 

425 
410 
463 
488 

33 
253 
220 
190 
141 
484 
487 
459 
153 

16 

3 

31 

31 

16 

16 

33 

31 

5 

314 

180 

229 

481 

69 

192, 

7 
416 

333 
no 

353 

334 

84 

23 
3>  25 

23 
4 

27 
418 
148 
318 
126 
468 
410 
353 
196 

159 
470 


206 


Ileoc/ECal  Tuberculosis 
Ileus  (see  Intestinal  Obstruction) 
Infectious  Fevers  in  Pregnancy       464 
Infiltration  Anaesthesia  .  .  . .      484 


494 


INDEX. 


Influenza  in  Pregnancy 
Injuries  of  the  Intestine 

—  —  —  Kidney 

—  —  —  Spleen 

—  —  —  Stomach 
Insolation,  Venesection  for 
Intercostal  Neuralgia 
Intermittent  Hydrarthrosis 
Intestinal  Actinomycosis 

■ —  Carcinoma 
— •  Colic    .  . 

—  Diseases 

—  Exclusion 

—  Injuries 

—  Obstruction 


227, 


209,  214, 


231,   2 

—  —  by  Gall-stone  204,  227, 

—  —  —  Occlusion 

—  —  —  Strangulation 
Paralytic   . . 

—  Paralysis 

—  Puncture 

—  Resection  230,   236,   238, 

—  Rupture 

—  Stenosis 

—  Torsion 

—  Tuberculosis    .  . 

—  Ulcer,    Peptic . . 
Intoxications,  Venesection  in 
Intrathoracic  Goitre 
Intubation  in  Diphtheria 
Intussusception    .  . 
Iodine  Blood  Reaction    . . 


PAGE 

464 

251 

399 

362 

251 

153 

68 

84 

211 

243 

237 

201 

230,  245 

•  ■      251 
284 

230,  322 

•  •      236 
■•      233 

232 

489 

236 

241,  244, 

251 

■  •      252 

243 

233 

206 

182 

153 

135 

94 

240 

259 


232, 


227, 


Jacksonian  Epilepsy     . .  4,  9,   16,  28 

Jaundice  309,  319,  320,  325,  331,  343, 

347,  378 

—  after  Anaesthesia        . .          . .  485 

—  in   Pregnancy..          ..           ..  469 

—  —  Sinus  Thrombosis  . .  20 
Jejunum,  Peptic  Ulcer  of  . .  182 
Joint  Arthrodesis              .  .           .  .  59 

—  Infection  in  Sinus  Thrombosis  20 

—  Intermittent  Hydrarthrosis  of  84 

—  Movable  Bodies  in     .  .           .  .  452 

—  Resection  . .  .  .  451,  453 
Joints,  Diseases  of  .  .  .  .  449 
Jugular  Vein  Thrombosis           . .  20 


of 


Kernig's  Sign     . . 
Kidney,  Abscess  of 

—  Angioneurotic  Haemorrhage 

—  Bright's  Disease  of    . . 

—  Calculus  of     . . 

—  Carcinoma  of . . 

—  Contusions  of . . 

—  Cystic  Disease  of 

—  Disease  in  Pregnancy 

—  Diseases  of     . . 

—  Fixation  of     . . 

—  Floating 

—  Functional    Value    of    the 

422,  426,  482 


•36,  37 
430 
387 
383 
389 
409 

399 
413 
465 
383 
404 
402 


Kidney,  Hydatid  Cyst  of 

—  Hydronephrosis  of 

—  Movable 

—  Neuralgia  of   . . 

—  Rupture  of 

—  Sarcoma  of 

—  Tuberculosis  of 

—  Tumours  of     . . 


Labour,  Induction  of     . . 
Laminectomy  in  Pott's  Disease 
Spinal  Fracture   . . 

—  —  Tubercular  Meningitis 
Laryngeal  Paralysis 

—  Tuberculosis    . . 

—  Tumours 

Laryngotomy  for  Stenosis 
Larynx,  Diphtheria  of    .  . 

—  Diseases  of      .  . 

—  Intubation  of  the 

—  Stenosis  of 
Lateral     Sinus,     Thrombosis    of 

the 

Leptomeningitis,  Acute  .  . 
Leucffimia  and  Operation 

—  —  Splenectomy 

—  in   Pregnancy.. 
Leucocytosis  in  Appendicitis 

—  —  Peritonitis 
Liver,  Abscess  of .  . 

—  Diseases  of 

—  Atrophic  Cirrhosis  of 

—  Gumma  of 
Local  Anaesthesia 
Lumbar    Puncture    in    Cerebral 

Abscess . . 
— Tumour   .  . . 

—  —  —  Meningitis 
Lung,  Abscess  of . . 

—  Actinomycosis  of 

—  Bronchiectasis  of 

—  Disease  and  Anaesthetics 

—  Diseases  of 

—  Foreign  Bodies  in  the 

—  Gangrene  of    .  . 

—  Hydatid  Disease 

—  Tuberculosis  of 

—  Tuberculosis  in  Pregnancy 
Lymphosarcomata  of  the  Media 

stinum  . . 


PAGE 

416 
418 
402 
387 
399 
409 
424 
409 


459 
45 
52 
36 
90 

461 


92 


93 


Malaria  in  Pregnancy  .  . 

—  the  Spleen  in. . 
Measles  in  Pregnancy 
Mediastinitis,    Suppurative 
Mediastinum,  Diseases  of  the 

—  Tumours  of  the 
Membranous  Enteritis    . . 
Meninges,  Gumma  of  the 
Meningitis,  Acute 

—  Serous 

—  Tubercular 
Meningo-encephalitis 


20 
37 

488 

355 
463 
258 
273 
),  338 
331 
342 
331 
483 

17 

12 

36,38 

105 

III 

99 

485 

99 

99 

102 

no 

109 

461 

135 


465 
355 
464 

133 
133 
135 

215 

I 

37 
37 
35 
37 


INDEX. 


495 


}'AGE 

Meralgia  Parsesthetica    . .  .  .  70 

Mesenteric  Vessels,  Embolism  of  217 

Mesentery,  Tumours  of  . .  .  .  295 

Meteorism  and  Anaesthetics  . .  485 

—  and  Laparotomy        . .  . .  479 

—  of  the  Flanks . .  ..  ••  229 
Migraine  . .  .  .  .  •  •  •  64 
Moebius'  Symptom  . .  . .  81 
Morphia  Narcosis  . .  •  •  486 
Mouth,  Diseases  of  the  . .  . .  159 
Movable  Kidney  . .          . .  . .  402 

—  Liver    . .          . .          . .  .  .  346 

Motor  Aphasia     . .          .  .  .  •  5 

Mucous  Colitis     . .          . .  . .  215 

Muscles,  Spasm  of  Neck . .  . .  74 

Myoma  of  the  Stomach  . .  . .  191 


Nasal  Diphtheria            . .  .  .  92 

Neck  Rigidity  in  Cerebral  Abscess  16 

—  —  —  —  Tumour     . .  . .  5 

■ Meningitis        . .  .  .  37 

Necrosis,  Fat        . .          . .  . .  369 

—  of  the  Pancreas  . .  . .  369 
Nephralgia  Haematurica.  .  .  .  387 
Nephrectomy,  Risks  of  .  .  .  .  482 

—  for  Renal  Calculus  . .  . .  396 
Contusions       . .  . .  401 

—  —  —  Tuberculosis    . .  . .  427 

—  —  ^—  Tumour            .  .  . .  412 

—  in  Pyelitis       .  .          . .  . .  432 

—  —  Pyonephrosis  . .  . .  422 
Nephritis   .  .          . .          . .  .  .  383 

—  Suppurative    . .          . .  . .  429 

—  in  Pregnancy  .  .          . .  . .  465 

Nephropexy          .  .          . .  . .  404 

Nephrotomy  in  Renal  Calculus. .  396 

—  for  Cystic  Kidney      . .  . .  415 

—  —  Renal  Contusion  . .  . .  400 

—  —  —  Tuberculosis  . .  .  .  427 
Nerve,  External  Cutaneous  . .  70 

—  Facial  . .          . .          . .  . .  73 

—  Occipital          . .          . .  . .  65 

—  Sciatic              . .          . .  . .  71 

—  Supra-orbital  . .          . .  . .  73 

—  Trigeminal  . .  : .  . .  63 
Nerves,  Diseases  of  the  . .  . .  63 

—  Intercostal       . .          . .  . .  68 

Nervous  Arthropathy     . .  . .  449 

—  Disease  and  Pregnancy  . .  470 
Neuralgia  of  Brachial  Plexus  . .  67 

—  —  External  Cutaneous  Nerve  70 

—  —  Fifth  Cranial  Nerve  .  .  63 

—  —   Occipital  Nerve    . .  . .  65 

—  —  Sciatic  Nerve        . .  . .  71 

—  in  Spinal  Tumours     . .  .  .  54 

—  Intercostal       . .          . .  .  .  68 

—  Renal   .  .          . .          . .  . .  387 

—  Trigeminal       . .          . .  . .  63 

Neuritis  in  Pregnancy    . .  . .  471 

—  Peripheral        . .          . .  . .  58 

Neuroses    . .          . .          . .  . .  81 

Nocturnal  Enuresis         . .  . .  443 

Nystagmus  in  Hydrocephalus  . .  24 
Leptomeningitis  . .  . .  37 


Obstetric  Paralysis 

59 

Obstruction,  Intestinal  . . 

231 

—  by  Gall-stones    204,  227,  23 

0,  322 

Occipital  Lobe,  Abscess  of 

16 

Tumour  of 

5 

—  Neuralgia 

65 

Occlusion,  Intestinal 

236 

CEsophagotomy    .  . 

173 

CEsophagus,  Carcinoma  of 

171 

—  Diseases  of     . . 

167 

—  Diverticulum  of 

168 

—  Foreign  Bodies  in       . . 

133 

—  Fusiform  Dilatation  of 

167 

—  Resection  of   . . 

172 

—  Stricture  of     . . 

171 

Omentum,  Tumours  of  . . 

295 

Operations,  Complications  after 

488 

—  General  Influence  of .  . 

477 

Optic  Aphasia 

16 

—  Neuritis  in  Cerebral  Abscess . 

16 

Tumour     . . 

4 

Hydrocephalus 

24 

Sinus  Thrombosis 

20 

Osteomalacia        . . 

453 

Osteomyelitis  of  the  Vertebrae. 

47 

Otitic  Cerebral  Abscess  .  . 

15 

Ovaries,  Effects  of  Removal  of. 

481 

Pachymeningitis,     External 

Purulent 

17 

Palsy  of  Children,  Cerebral 

31 

Pancreas,  Calculus  of     . 

373 

—  Carcinoma  of  . . 

377 

—  Cysts  of 

374 

—  Diseases  of       . . 

369 

—  Inflammation  of 

369 

—  Necrosis  of     . . 

369 

—  Resection  of  . . 

378 

—  Tumours  of     . . 

377 

Pancreatitis 

369 

Paralysis,  Laryngeal 

90 

—  of  Blood-vessels 

50 

—  Intestinal 

23 

2,  489 

—  Obstetric 

59 

Pelvic  Peritonitis 

272 

Peptic  Ulcer 

182,  489 

Perforating  Ulcer  of  the  Foot  . 

75 

—  —  —  —  Stomach     . . 

178 

Perforative   Peritonitis   179,   252 

.   257. 

275 

Pericarditis 

141 

—  Purulent 

142 

Perihepatitis,  Chronic     . . 

284 

Perinephritis         . .            390,  420,  434 

Peripheral  Nerves,  Diseases  of. 

63 

—  Neuritis 

58 

Periproctitis 

222 

Peritoneal  Adhesions 

284 

—  Cavity,  Effects  of  Opening. 

479 

Peritoneum,  Diseases  of . . 

271 

—  Tumours  of     . . 

295 

Peritonitis,  Acute  Circumscribed     271 

—  Adhesive 

283 

—  Chronic  Exudative    . 

282 

496 


INDEX. 


PAGE 

Peritonitis,  Chronic  Indurative. .  283 

—  Diagnosis  from  Obstruction  278 

—  Diffuse              . .           .  .  257,  275 

—  Fibrino-purulent         .  .  257,   275 

—  in  Appendicitis           .  .  .  .  257 

—  Pelvic  .  .           . .           .  .  . .  272 

—  Perforative      .  .  179,   252,   257,  275 

—  Traumatic       . .           . .  .  .  282 

—  Tubercular      . .           .  .  .  .  287 

Pernicious  Anasmia  in  Pregnancv  463 

Petit  Mai '.  28 

Pharyngitis,  Septic          . .  . .  160 

Pharynx,  Diseases  of  the  .  .  159 

Pleura,  Diseases  of           ..  ..  117 

—  Empyema  of  ..           ..  117,  301 

—  Tumours  of     . .          . .  .  .  128 

Pleurisy     . .          . .          . .  . .  117 

—  in   Pregnancy..          ..  ..  462 

Plexus,  Brachial,  Neuralgia  of.  .  67 
- —  Cervical,  Neuralgia  of  .  .  65 
Pneumonia  and  Anesthesia  .  .  485 
Pulmonary  Abscess  . .  105 

—  —  —  Gangrene         . .  . .  102 

—  in   Pregnancy..           ..  ..  462 

—  Post-operative            .  .  4S0,  48S 

—  Venesection  for  .  .  . .  154 
Pneumothorax      . .           .  .  123,  301 

—  Operative         . .           .  .  . .  478 

—  Traumatic       . .          . .  .  .  125 

Pneumotomy  for  Abscess  . .  107 

—  —  Bronchiectasis      . .  .  .  100 

—  —  Gangrene  .  .           .  .  .  .  103 

Hydatid  Cyst       . .  .  .  1 11 

—  —  Tuberculosis          .  .  .  .  109 
Poliomyelitis,  Acute        .  .  .  .  57 
Polyneuritis  in  Pregnancy  . .  471 
Porro's     Operation     for     Osteo- 
malacia              .  .           .  .  . .  455 

Portal  Thrombosis           .  .  .  .  259 

Post-operative   Psychic   Disturb- 
ances     . .          .  .           .  .  .  .  477 

Pott's  Disease       .  .          . .  .  .  43 

Pregnancy,  Albuminuria  in  .  .  465 

—  Anaemia  in       .  .          .  .  . .  463 

—  Appendicitis  in           .  .  264,  468 

—  Cachexia  in     . .          .  .  . .  464 

—  Cardiac  Disease  in      .  .  . .  459 

—  Cholelithiasis  in          .  .  .  .  469 

—  Diphtheria  in.  .          ..  ..  464 

—  Diseases  of  Blood  in .  .  .  .  463 

—  Enteric  Fever  in        .  .  . .  464 

—  Epilepsy  during         .  .  . .  470 

—  Hsmatemesis   during  ..  467 

—  and  Haemophilia  .  .  . .  463 
— -  —  Heart  Disease       .  .  . .  459 

—  Hysteria  during         . .  . .  470 

—  Infectious  Fevers  in . .  . .  464 
■ — •  Influenza  in    . .          . .  . .  464 

—  Jaundice  in     . .          . .  .  .  469 

—  Kidney  Disease  in      .  .  . .  465 

—  Leucaemia  in  .  .          .  .  .  .  463 

—  Malaria  in       .  .          . .  .  .  465 

—  Measles  in       . .          . .  . .  461 

—  Nephritis  in    . .          . .  . .  465 

—  and  Nervous  Disease  . .  470 


Pregnancy.  Neuritis  in 

—  Pernicious  Anemia  i, 

—  Pleurisy  in 

—  Pneumonia  in 

—  Polioneuritis  in 

—  Pyelonephritis  in 

—  Scarlatina  in  . . 

—  Scurvy  in 

—  Small-pox  in  . . 

—  Tetanus  in 

—  Tuberculosis  in 

—  Typhoid  Fe\-er  in 

—  Vomiting  in    .  . 
Premature  Labour,  Induction  of 
Proctitis     .  . 

Pseudoleucffimia  and  Operation 
Psychic  Disturbances  after  Opera- 
tion        . .  .  .  . .         477, 

Pulmonary  Tuberculosis 

—  Gangrene  and  Pneumonia   .  . 

—  Abscess  and  Pneumonia 
Pulse  after  Operations   . . 
Puncture  for  Anasarca    .  . 

—  of  the   Cerebral  Ventricles   12, 


PAGE 

471 
463 
462 
462 
471 
467 
464 
463 
464 
465 
461 
464 
468 

459 
222 
356 


109 
102 
105 


—  Intestinal 

—  Lumbar 

—  of  the  Pericardium 

Pyelitis 

Pyelonephritis 

—  in   Pregnancy . . 
Pylephlebitis,  Septic 
Pylorus,  Carcinoma  of    .  . 
— ■  Congenital  Stenosis  of 

—  Stenosis  of 
Pyonephrosis 


12,   17 


148 

25, 

36,  38 

236 

36,  38 

142 

429 

•  •      430 

..      467 

..      274 

185,   193 

196 

181,  192 

390,  418 


390, 


Pyopneumothorax,  Subphrenic.  .      124 


Rectu.m,  Carcinoma  of  . .           .  .  246 

—  Inflammation  of         . .          . .  222 

—  Stricture  of      . .           . .          . .  223 

—  Ulcers  of          . .           .  .           .  .  247 

Renal   Abscess      . .          .  .          .  .  430 

— ■  Arteries,  Aneurysm  of          .  .  410 

—  Calculus           . .          . .          . .  389 

—  Colic           385,  38S,   391,  400,  402, 

416,  420,  425,  431 

—  Contusions       .  .           .  .           . .  399 

—  Disease,  Cryoscopy  in  422,  426,  482 

—  Neuralgia         .  .           .  .          . .  387 

—  Pelvis,  Disease  of       .  .          . .  383 

—  Tuberculosis    . .          .  .          . .  427 

Respiratory  Organs  in  Pregnancy  461 
Retropharyngeal  Abscess,  46,  47, 94, 161 

—  Cellulitis           .  .          .  .          . .  161 

Roth-Bernhardt's  Disease          . .  70 

Rupture  of  the  Intestine           . .  252 

—  —  —   Kidney             . .          . .  399 

Spleen               . .          . .  362 

— Stomach          ..          ..  251 


Sarcom.a.  of  the  Brain    . .  . .  i 

—  —  —  Kidney  . .  . .      409 


INDEX. 


497 


Sarcoma  of  the  Liver    . . 

— Spleen 

Scarification  for  Anasarca 
Scarlatina  in  Pregnancy.  . 
Schleich's  Infiltration  Anassthesia 
Sciatic  Nerve,  Neuralgia  of 
Sclerosis,  Multiple 
Scurvy,  in  Pregnancy 
Sensory   Aphasia. . 
Sepsis  and  Chloroform    . . 
Septic  Pharyngitis 
Shock,  Operative 
Sigmoid  Flexure,  Volvulus  of  . . 
Sinus  Phlebitis     . . 

—  Thrombosis  .  . 
Sinus,  Thrombosis  of  Cavernous 

—  Lateral 

Skull,  Effects  after  Opening 

—  Erosion  by  Tumour  .  . 

—  Trephining  for  Haemorrhage 

—  —  —  Meningitis 
Palsy    . . 

—  —  —  Tumour 
Small-pox  in  Pregnancy 
Spasm,  Facial 

—  of  Cervical  Muscles  . . 
Spasmodic  Torticollis 
Spinal  Anaesthesia 

—  Canal,  Opening  of     .  . 

—  Column  and  Cord,  Diseases  of 

—  Cord  Compression      . .      45, 

—  —  Partial  Lesions  of 

—  —  Section  of . . 
Traumatic  Affections  of 

—  —  Tumours  of 
Spine,  Fracture  of 

—  Osteomyelitis  of 

—  Tubercular  Disease  of 
Spleen,  Abscess  of 

—  Chronic  Hyperplasia  of 

—  Diseases  of 

—  Floating 

—  Hydatid  Cyst  of 

—  in  Banti's  Disease 

Malaria 

Pseudoleucaemia  .  . 

—  Rupture  of  .  . 
— •  Tumours  of  .  . 
Splenectomy  355,  358,  361,  363 


••      331 
353.   356 


464 

484 

71 

10 

463 

5 

485 

160 

478 

233 

19 

19 

21 

19 
480 
7 
34 
38 
31 

ID 

464 

73 

74 

74 

484 

480 

43 

47,  49 

50 

44 

48 

54 


Splenopexy 

Spondylitis,  Traumatic  .  . 

—  Tubercular 
Status  Thymicus. . 
Stenosis,   Congenita],   of  Pylorus 

—  of  Duodenum. . 

—  —  Intestine   . .  . .         227 

—  —  Larynx 
CEsophagus 

—  —  Pylorus 
Sternum,  Abscess  of 
Stomach,  Atonic  Dilatation  of.. 

—  Carcinoma  of  . . 

—  Chr'Miic  Catarrh  of    .  . 

—  Dilatation  of  . . 


47 
43 
364 
353 
353 
359 
353 
357 
355 
356 
362 
353 
364, 
483 
361 
45,  49 
43 
484 
196 
204 
244 

89 
171 
192 

134 
194 
183 
1 80 
192 


Stomach,  Diseases  of 

—  Ectasis  of 

—  Foreign-body  Tumours  of 

—  Hair-ball  in     . . 

—  Hour-glass 

—  Injuries  of 

—  Myoma  of 

—  Paralysis  after  Operation 

—  Perforating  Ulcer  of. . 

—  Resection  of   .  . 

—  Rupture  of     .  . 

—  Simple  Tumour  of     .  . 

—  Subcutaneous  Injuries  of 

—  Ulcer  of 

Strangulation,  Intestinal 
Stricture  of  Rectum 
Stridor,  Laryngeal 
Subphrenic  Abscess  177, 

Succussion,  Hippocratic. . 
Sun-stroke 

Suppurative   Mediastinitis 
Sympathetic,  Resection  of 
Syringomyelia 
Syringomyelic  Arthropathy 


PAGE 

..      177 

192 

igo 

190 

192 

..      251 

.  .      191 

..      489 

..      178 

..      182 

•  •      251 

190 

■  ■      251 

..      177 

••      233 

223 

91,    92 

255,   301 

124 

153 

133 

83 

59 

449 


Tabetic  Arthropathy     . .  . .  449 

Tachycardia,   Post-operative  .  .  489 

Talma-Morison   Operation  . .  344 

Tapping,  for  Ascites        .  .  . .  299 

Temperature  after  Operation  . .  489 

Tendon,  Section  of,  in  Torticollis  75 

—  Transplantation  .  .  .  .  59 
Testicle,  Removal  of  . .  . .  481 
Tetanus,  in  Pregnancy  . .  . .  465 
Tetany     in     Dilatation     of  the 

Stomach             . .          . .  . .  194 

—  in   Pregnancy..          ..  ..  471 

Thoracocentesis    . .          . .  . .  119 

Thoracotomy        .  .          . .  . .  121 

Thrombosis  of  Mesenteric  Vessels  217 

—  Jugular  Vein  .  .           .  .  .  .  20 

—  Lateral  Sinus..          ..  ..  20 

—  Portal  . .          .  .          . .  . .  259 

Thyroid,  Resection  of     . .  83,  481 

Tic  Douloureux   . .          . .  . .  63 

Tonsillotomy,  Indications  for   .  .  159 

Tonsils,  Hypertrophy  of  .  .  159 

Torsion,  Intestinal           . .  . .  233 

Torticollis,  Spasmodic     . .  . .  74 

Tracheotomy  in  Aneurysm  .  .  147 

Diphtheria             . .  . .  93 

-^  —  Exophthalmic   Goitre  .  .  82 

—  —  Laryngeal   Paralysis  . .  91 

—  —  —  Stenosis  . .  .  .  89 
Trephining,  Epilepsy  after  .  .  480 
Trigeminal  Neuralgia  . .  . .  63 
Tubercle  of  the  Choroid.  .  •  •  35 
Tubercular  Disease  of  Spine  . .  43 

—  Meningitis       . .          . .  .  .  35 

—  Peritonitis       .  .          .  .  .  •  287 

—  Spondylitis      ..          ..  ..  43 

Tuberculosis  and  Operation  .  .  487 

—  of  the  Bladder  .  .  424,  444 
Brain i,  n 

32 


498 


Tuberculosis  of  the  Intestuie  .  • 

Kidney 

Larynx 

Lung    . .  •  •         109 

Vertebrae 

Tumours,  Cerebral 

—  Laryngeal 

—  of  the  Brain  . . 

Cerebellum 

Frontal   and   Occipital 

Lobe 

Kidney 

. Liver    . . 

l Mediastinum  .  • 

Mesentery 

Omentum 

Pancreas 

Peritoneum     .  ■ 

Pleura 

Rolandic  Region 

Spinal  Cord     • . 

Spleen 

• Stomach 

Typhoid  Fever,  Perforation  m . . 
_1  —  in  Pregnancy 


Ulcer,  Duodenal 
—  Gastric 


INDEX. 


PAGE 
206 
424 
461 

,    461 

43 


5 
409 

331 
135 
295 
295 
377 
295 
128 

14 

54 

353 

190 

277 
464 


201 
177 


Ulcer,  Rectal        

Ulcerative  Colitis 
Ulcers,  Intestinal,  Artificial  Anus 
in 

—  Peptic  Intestinal 

Urzemia      .  .  384.  39i»  4i4. 
Diagnosis  from  Peritonitis  . . 

—  Venesection  for 
Ureteral  Calculus 


Venesection  in  Chlorosis 

Circulatory  Disturbance . . 

Eclampsia 

Insolation.. 

Intoxications 

Pneumonia 

Ursomia 

Vertebra3,  Angular  Curvature  of 

—  Fractures  of   .  . 

—  Luxation  of     •  ■ 

—  Osteomyelitis  of 

—  Tuberculosis  of 

—  Tumours  of     •  •  •  •  •  • 

Vertebral  Canal,  Opening  of     •  • 
Volvulus  of  the  Sigmoid  Flexure 
Vomiting,    Excessive,    m    Preg- 
nancy 


PAGE 
247 
213 

214 


420 
278 
153 

394 


155 
154 
154 
153 
153 
154 
153 
44 
48 

49 
47 
43 
54 
480 

233 
468 


JOHN 


WRIGHT    AND    CO.,    PRINTERS    AND    PUBLISHERS, 


BRISTOL. 


.      DUE  DATE 

QCU 

L  m  1 

WJsM 

i 

mrr^ 

ioh's. 

W} 

1 

Printed 
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